1

# of children______

Amt. collected______

Check___ or Cash ___

KINGSTON TOWNSHIP

SUMMER RECREATION PROGRAM

REGISTRATION, CONSENT AND GENERAL RELEASE OF ALL CLAIMS

THIS AGREEMENT made this day of , 20____, by and

between ______as the PARENT(S)OR GUARDIAN(S)OF CHILD(REN)

______

(Name of Child) (age) (Name of Child)(age)

______

(Name of Child) (age) (Name of Child)(age)

residing at ______

(Full Address)

of each herein called "RELEASOR"

AND

THE TOWNSHIP OF KINGSTON, Luzerne County, Pennsylvania, a municipality organized and existing under the laws of the Commonwealth of Pennsylvania, herein called "RELEASEE"

Form is a consent and a release, whereby the RELEASOR(S) consent to the CHILD'S participation in a recreation program(s) sponsored by the RELEASEE and extinguish their individual and mutual rights and claims against THE TOWNSHIP OF KINGSTON as herein enumerated.

NOW, THEREFORE, with the intent to be legally bound and in consideration of SEVENTY FIVE ($75.00) Dollars for the first child in a family and FIFTY-FIVE ($55.00) Dollars per child thereafter, receipt of which is hereby acknowledged, and other good and valuable consideration, including but not limited to, participation by the CHILD in special physical, intellectual and character-enhancing events and recreational activities sponsored by THE TOWNSHIP OF KINGSTON, the RELEASOR(S) agree as follows:

1. The RELEASOR(S), on behalf of themselves, their heirs, personal representatives and assigns, hereby consent to the CHILD'S participation in a recreation program(s) sponsored by THE TOWNSHIP OF KINGSTON and hereby fully release and discharge THE TOWNSHIP OF KINGSTON, its successors and assigns, from all rights, claims and actions which RELEASOR(S) and their heirs, personal representatives, and assigns may have or may hereafter have against THE TOWNSHIP OF KINGSTON its successors and assigns, arising out of the following activities.

(a) The transportation of CHILD from Center Street Park to Francis Slocum State Park and return, and

(b) The participation by CHILD in hiking and swimming activities and all other aspects and events of the recreational program(s), and

(c) The participation by CHILD on field trips and activities related thereto by private transportation from Center Street Park to various field trip locations, and return, as may be scheduled during the course of the program.

2. This consent and release is intended by the parties to release all injuries, damages, or losses of whatever nature to the RELEASOR(S) person and property, real or persona, whether known, unknown, unforeseen, foreseen, patient or latent, which the RELEASOR(S) may have and may in the future have against THE TOWNSHIP OF KINGSTON. The RELEASOR(S) understand and acknowledge the significance and consequence of such specific intention to release all claims, and they hereby assume unqualified and full responsibility for the total costs, risks, and burdens of any injuries, damages, or losses of whatever nature that they, individually or jointly, may incur from the participation by the CHILD in the recreation program(s) sponsored by THE TOWNSHIP OF KINGSTON and, more specifically, those events or activities described in Paragraph 1 hereof.

3. This release is freely and voluntarily executed by the RELEASOR(S) after having been apprised of all relevant general information furnished by THE TOWNSHIP OF KINGSTON or its authorized representative(s) with respect to the nature of the recreation program(s) of THE TOWNSHIP OF KINGSTON and, more specifically, those events or activities described in Paragraph 2 hereof, and after a thorough review and consideration by them of potential risks to the RELEASOR(S), and possible future medical care and treatment as a result of the participation in the above-described event or activity by the CHILD. The RELEASOR(S) in executing this agreement do not rely on any inducements, promises, or representations made by THE TOWNSHIP OF KINGSTON, or its representative(s), other than the general description of such event or activity as is contained herein.

4. The RELEASOR(S)have read this consent and release, and they hereby acknowledge their complete understanding of its consequences.

5. The RELEASOR(S) further acknowledge receipt of a copy of the Recreation Program Rules For a Successful Summer and agrees to insure compliance by their child or children enrolled in the program.

6. The RELEASOR(S) acknowledge(s) the age limitations of the program, which are the completion of Kindergarten up to and including the sixth grade and will not be older than twelve (12) years of age during the program. (Will not turn thirteen (13) years of age during the program)

PARENT(S) OR GUARDIAN(S)(To be signed in front of Witness:)

______

(Signature)

Phone:______home

______work

cell

pager

Witness:THE TOWNSHIP OF KINGSTON

BY:

Counselor/Administrative staff Kathleen Sebastian, Township Manager

To be filled out by Counselor/Administrative staff

RELEASOR(S) has shown the following as proof of residency:

(Check one) Drivers License, Tax Receipt, Tax Duplicate, Other

T-shirt issued______(Initial)

Size(s) ______

The RELEASOR(S) acknowledge(s) the receipt of one (1) Kingston Township logo t-shirt per child registered. Parent/Guardian Initial______.

NO REFUNDS AFTER FIRST WEEK OF CAMP