REGISTRATION AND RELEASE AGREEMENT
Both Sides of the Form Must be completed
Program Location:
q Beaconsfield School
q Carleton Community Centre
q Crescent Valley Resource Centre
q Glen Falls School
q Lakewood Heights School
q Lorneville Community Centre
q Milford Community Centre
q St. Rose Playground/Lancaster Baptist Church
Child’s Full Name:
Current Age: Date of Birth: q Male or q Female
Medicare Number:
Special Care Information: Indicate any allergies, medical, dietary, or behavioral information about your child. Please note that while we aim to be an inclusive program, children must be able to self-care (bathroom) and able to actively participate within a supervised group setting.
Primary Parent/Guardian:
Relationship to child:
Address:
Telephone: Email:
Are you the daytime caregiver? q Yes q No
If no, please provide the contact information of the parent or guardian who is available during the day should your child be required or desire to leave the program.
Daytime Caregiver:
Relationship to child:
Address:
Telephone:
Please list any other guardians who have permission to retrieve your child from Playground Program:
Name: Telephone:
Name: Telephone:
CITY OF SAINT JOHN RELEASE AGREEMENT
IN CONSIDERATION OF BEING PERMITTED TO PARTICIPATE IN THIS CITY ACTIVITY OR USE OF ANY CITY OF SAINT JOHN OR PROVINCE OF NEW BRUNSWICK FACILITIES IN CONNECTION WITH THIS PROGRAM, THE UNDERSIGNED AGREES TO THE FOLLOWING:
THE PARENT/GUARDIAN ASSUMES FULL RESPONSIBILITY of the Participant’s arriving to and from any Playground Program site and, further acknowledges, that the Parent/Guardian will be available, at all times, to the Participant, if the Participant wishes to leave the program at any time.
THE PARENT/GUARDIAN ACKNOWLEDGES that a parent, guardian or responsible adult will be at home where the Participant leaves the program and, further acknowledges, that the Parent/Guardian accepts full responsibility of the Participant when the Participant walks unaccompanied from any playground site or Community Centre.
SINCE THERE ARE INHERENT RISKS ASSOCIATED WITH EVERY ACTIVITY, I the Parent/Guardian, of the Participant, hereby state that I have considered risks and hereby give my permission for the Participant to attend and participate in the mentioned activities as well as any associated activities.
THE PARENT/GUARDIAN SHALL INDEMNIFY AND SAVE HARMLESS the City of Saint John from all damages, costs, claims, demands, actions, suits or other proceedings by whomsoever claimed, made, brought or prosecuted in any manner and whether in respect of property owned by others or in respect of damage sustained by others based upon or arising out of or in connection with the performance of this Agreement or anything done or purported to be done in any manner hereunder, but only to the extent that such damages, costs, claims, demands, actions, suits or other proceedings are attributable to and caused by the Participant’s and/or the Parent/Guardian’s negligence, errors or omissions.
IN NO EVENT SHALL THE PARTICIPANT AND/OR THE PARENT/GUARDIAN BE OBLIGATED TO INDEMNIFY the City of Saint John in any manner whatsoever in respect of any damages, costs, claims, demands, actions, suits or other proceedings caused by the negligence of the City of Saint John, or any person for whom the City of Saint John is responsible.
q I have received and read the Parent/Guardian Information Sheet.
q I consent to my child’s photo to be taken during the summer Playground Program activities for potential media use.
q I have read and agree to the terms of this release.
Signature Date