Registration and Release Form
City of Brampton – Rockwall

Please read and fill in all applicable areas on front and back:

Part A: Child’s Information

Child’s Last Name / Child’s First Name / Sex M/F
Family Address / Apt/Unit# / Home phone #
( )
City / Postal Code / Email
Parent/Guardian’s Name 1 Male
Female / Bus. Phone #
( ) / Cell Phone #
( ) / Home Phone #
( ) / Transportation Contact
Yes No
Parent/Guardian’s Name 2 Male
Female / Bus. Phone #
( ) / Cell Phone #
( ) / Home Phone #
( ) / Transportation Contact
Yes No

Part B: Family Medical/Special Needs Information

To best serve the needs of participants, we require the following information to be complete for all participants with medical or special needs. (Please only check of applicable conditions)
1. Allergies 2. ADD/ADHD 3. Behavioral Conditions 4. Physical/Developmental Impairment 5. Other Special Conditions Specify
If any of the above has been checked off, please complete the appropriate section(s) on the Participant Medical/Special Needs Profile attached.

Part C: Emergency Contact Information & Child Transportation
(Please provide a different number than the ones listed for the parents)

Emergency Contact Name / Home Phone #
( ) / Bus. Phone #
( ) / Cell Phone #
( )
Relationship to Student / Transportation Contact
Yes No
Emergency Contact Name / Home Phone #
( ) / Bus. Phone #
( ) / Cell Phone #
( )
Relationship to Student / Transportation Contact
Yes No


Waiver

In consideration of the City of Brampton permitting me to register my child listed on this registration form to participate in activities of its Community Services Department, I herby:
a) certify and represent that I have legal authority to authorize medical care and consent for my registered child
b) authorize the City of Brampton to provide such medical care to my registered child as the City of Brampton may deem necessary in the event of injury, and I agree to pay for all expenses incurred by the City of Brampton in the provision of such medical care; and
c) agree to release, indemnify and save harmless the City of Brampton from and against all claims, proceedings and/or actions in respect of any costs, losses, damage or injury arising by reason of my registered child’s participation in any activities offered by the City of Brampton’s Community Services Department, or by reason of the provision of medical care by the City of Brampton to my registered child.