COLONEL TOWN RECREATION

16 High St.

Lancaster, NH 03584

Phone: (603) 788-3321/Fax: (603) 788-3204
Email:
Website:

Check us out on Facebook as “Colonel Town Recreation Dept.”

WinterRegistration – 2013-2014

If no one is in the office, please place registration form in the red box outside the office.

Name: ______Phone #: (______) ______-______

Address: ______

Birth Date: _____/_____/_____ Child’s Age: _____ Sex: _____ Grade in School: ______

Cell Phone: ______

Parent/Guardian Name: ______Cell Phone #: (______) ______-______

Parent/Guardian Email Address: ______

In consideration of participation in the ColonelTown Recreation programs, the undersigned agrees that their likeness, or the likeness of their child/ward, may be photographed or videotaped and that such image(s) may be published in an outlet used to promote or publicize the ColonelTown Recreation program.

X______X______

Parent/Guardian Signature Date

Check all that Apply / PROGRAMS / COST
Lancaster / Out-of-Town
Arts & Crafts: Thanksgiving (Ages 5-12)
(Native American headdresses) Thursday, 11/21 4:00-4:45 / $ 6 / $ 7
Arts & Crafts: Christmas (Ages 5-12)
(Christmas stocking decoration) Thursday, 12/12 4:00-4:45 / $ 6 / $ 7
Arts & Crafts: Thanksgiving (Ages 5-12)
(Winter Birdhouse Thermometer Craft) Thurs., 2/13 4:00-4:45 / $ 6 / $ 7
Calorie-Burner Fusion Saturdays 8:20-9:30am / $ 3/class / $ 3/class
Colonel Town Spirit Squad (Grades 2-6) Begins in January / $20
(includes cheer shirt and ribbon) / $25
(includes cheer shirt and ribbon)
Father/Daughter Dance Sunday, 2/9, 12:00-3:00pm / $25/couple
(prepaid)
$35/couple
(paid at the door) / $25/couple
(prepaid)
$35/couple
(paid at the door)
Flexibility Fusion Wednesdays 5:30-6:30pm / $ 3/class / $ 3class
Gymnastics (Ages 5-10) Mondays 3:30-4:30pm Nov. 18-Dec. 16 / $ 27 / $ 32
Middle School Dance (Grades 5-8) Friday, Nov. 15, 6:30-8:00pm / $ 4 / $ 4
Seniors on the Move Mondays/Wednesdays/Fridays 8:30-9:30am / $ 1/class / $ 1/class
Start Smart Kid’s Gym(Ages 2-5) Wednesdays 10:30-11:15 Nov. 20-Dec. 11 / $ 12 / $ 15
Start Smart Kid’s Gym(Ages 2-5) Wednesdays 10:30-11:15 Jan. 29-Feb. 19 / $ 12 / $ 15
Wrestling (Grades 1-4) Schedule TBA will start in Jan. ** at WMRHS ** / $ 20 / $25

Paperwork that has been completed and returned: TOTAL DUE: $______

______Waiver and Release of Liability______Emergency Information & Consent

NOTE: All paperwork must be completed and fees paid before your child participates in the above programs.

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(For Col. Town staff only) Date Paid: ____/____/____ Method (Circle One): Check #______or Cash Amt Pd: $______

Please Note: A dog and cat reside on the second floor at Colonel Town.


COLONEL TOWN RECREATION

16 High St.

Lancaster, NH 03584

Phone: (603) 788-3321/Fax: (603) 788-3204

Email: Website:

Youth BasketballRegistration – 2013-2014

** Special Signup Day – Saturday, November 16th 1:00-3:00pm (during Open Gym)**

If no one is in the office, please place registration form in the red box outside the office.

Name: ______Phone #: (______) ______-______

Address: ______

Birth Date: _____/_____/_____ Child’s Age: _____ Sex: _____ Grade in School: ______

Cell Phone: ______

Parent/Guardian Name: ______Cell Phone #: (______) ______-______

Parent/Guardian Email Address: ______

In consideration of participation in the ColonelTown Recreation programs, the undersigned agrees that their likeness, or the likeness of their child/ward, may be photographed or videotaped and that such image(s) may be published in an outlet used to promote or publicize the ColonelTown Recreation program.

X______X______

Parent/Guardian Signature Date

Check all that Apply / BASKETBALL PROGRAMS
(Basketball is sponsored by Passumpsic Savings Bank) / COST
Lancaster / Out-of-Town
Start Smart Basketball – Ages 3-6 Saturdays 10:00-10:45am Nov. 23-Dec. 14 / $ 12 / $ 16
Basketball – Grades 1-2 Schedule TBA Starts Saturday, Nov. 23 at 11:00am / $ 20 / $ 25
Basketball – Grades 3-4
Season schedule TBA Boys will start 11/18 @5:00pm; Girls will start 11/20 @4:00pm / $ 25 / $ 30
Basketball – Grades 5-6
Season Schedule TBA Boys will start 11/19 @3:30pm; Girls will start 11/19 @5:00pm / $ 30 / $ 35
HOODED SWEATSHIRTS – The design will include the player’s name on the back. Any players or parents interested in ordering sweatshirts should complete an order form which will be available at Colonel Town. In the past, parents have ordered sweatshirts for themselves to wear to the games. / $ 30 / $ 30

TOTAL DUE: $______

Paperwork that has been completed and returned:

______Waiver and Release of Liability______Emergency Information & Consent

NOTE: All paperwork must be completed and fees paid before your child participates in the above programs.

WE NEED YOUR HELP!!!!

Volunteer Basketball Coaches and Snack Bar Helpers are Needed!

_____ Yes, I (______) am willing to coach.

_____ Yes, I (______) am willing to help in the snack bar.

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(For Col. Town staff only) Date Paid: ____/____/13 Method (Circle One): Check #______or Cash Amt Pd: $______

Please Note: A dog and cat reside on the second floor at Colonel Town.

COLONEL TOWN RECREATION

WAIVER AND RELEASE OF LIABILITY

Read Before Signing

In consideration of being allowed to participate in any way in the Colonel Town Recreation Winter Programs, related events and activities, the undersigned acknowledges, appreciates and agrees that:

  1. The risk of injury to ______(participant’s name) from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment and personal discipline may reduce this risk, the risk of serious injury does exist; and,
  1. I am aware that there is a dog and cat that both reside on the second floor of the community house; and,
  1. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my participation; and,
  1. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and being such to the attention of the nearest official immediately; and,
  1. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Colonel Town Recreation

their officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“RELEASES”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property. WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

X______DATE SIGNED: ______

(Participant’s Signature)

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FOR PARTICIPANTS OF MINORITY AGE

(BELOW THE AGE OF 18 AT THE TIME OF REGISTRATION)

This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all Releasees, and for myself, my heirs, assigns and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THEIR NEGLIGENCE.

X______DATE SIGNED: ______

(Parent/Guardian Signature)

COLONEL TOWN RECREATION

EMERGENCY INFORMATION & CONSENT

(ONE FOR EACH ATHLETE/PARTICIPANT)

Participant’s Name ______Age: ______Birthdate: ____/____/____

Address ______

Phone (_____) ______Work Phone (_____) ______Email ______

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Father’s Name ______

Address ______

Employer ______Cell Phone (_____) ______

Phone (_____) ______Work Phone (_____) ______Email ______

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Mother’s Name ______

Address ______

Employer ______Cell Phone (_____) ______

Phone (_____) ______Work Phone (_____) ______Email ______

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Family Medical Insurance:

Carrier ______

Policy #______Group #______

Physician’s Name ______

Physician’s Phone ______

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Health Information:

Allergies (list) ______

Other Medical Conditions (list) ______

Medications & Dosages ______

I hereby grant consent to any and all health care providers designed by Colonel Town Recreation to

provide ______any necessary medical care as a result of any

(name)

injury or illness. This consent includes First Aid and transportation to/from health care providers.

______

Participant (Adult) Signature Date

______

Parent/Guardian Signature Date

“It’s NotMe. It’s Not You. It’s Us.”Lou Leaver