FREDONIA-POMFRET RECREATION DEPARTMENT
WINTER ACTIVITY APPLICATION
NAME______TELE. #______
ADDRESS______AGE____ DATE OF BIRTH______
PARENT/GUARDIAN NAME______EMERGENCY # ______
Program Participation In (Circle one):
Basketball Gr. 2-4Basketball Gr. 5-8Wrestling
The Recreation Department conducts a diverse year-round program of leisure activities for the enjoyment of Village of Fredonia and Town of Pomfret residents.
Check one:
______Village of Fredonia Resident ______Town of Pomfret Resident
In consideration of the privilege of participating in this recreation program of the Fredonia-Pomfret Recreation Department, I HEREBY RELEASE THE FREDONIA-POMFRET RECREATION DEPARTMENT, VILLAGE OF FREDONIA, TOWN OF POMFRET AND FREDONIA CENTRAL SCHOOL DISTRICT FROM ANY AND ALL LIABILITY RESULTING FROM ANY ACCIDENT THAT MIGHT OCCUR. I HEREBY STATE THAT THE APPLICANT NAMED HEREON DOES NOT HAVE A PHYSICAL DISABILITY OR CONDITION THAT COULD ENDANGER HIS OR HER HEALTH AS A RESULT OF PARTICIPATING IN THIS ACTIVITY. The applicant agrees to follow all rules set up by the Recreation Department of the Village of Fredonia and Town of Pomfret, New York, applicable to this activity. Participation in the Fredonia – Pomfret recreation department’s winter program hereby consents to the taking of photographs, movies or video tapes of the individual named above. I grant the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release the Fredonia – Pomfret Recreation Department and employees, officials of the village of Fredonia, and their volunteers from all claims, demands, and liabilities whatsoever in connection with the above. No names of participates will be used.
I HEREBY GRANT PERMISSION FOR MY SON, DAUGHTER OR WARD______
TO PARTICIPATE IN THIS FREDONIA-POMFRET RECREATIONAL ACTIVITY.
______
Signature of Parent or GuardianAddressTelephone No.
FREDONIA-POMFRET SAFETY AND MISBEHAVIOR GUIDELINES
Misbehavior includes: foul language, name calling, hitting, fighting, playing unfair, not following rules of activity, unauthorized use of telephone, unauthorized use of building and play equipment, damaging property, or any activity that may result in injury of oneself or others or damage to supplies, equipment or property in that play area. The following policy will be enforced should misbehavior occur:
- Verbal warning to child with parent notification from the recreational attendant.
- Written warning sent home in which parent must sign to acknowledge misbehavior. Child will not be allowed back unsupervised by parent or guardian until form is handed back in.
3. Child must be accompanied by parent, guardian or sitter, 16 years or older when visiting play area.