Town of Southbridge

Police Department

 

Cops N Kids After School Basketball Program

6p.m. to 8:45p.m.

 

Registration Form                                                                                 Group__________

 

Name of Student__________________________________________  Age_________

 

Entering Grade____ Date of Birth _________Shirt Size ____Phone#_______________

 

Address________________________________________________________________

 

Email Address______________________________________________Gender ______

 

Parent Names ___________________________________________________________

 

Emergency Contacts (2):_________________________/_________________________

 

List special dietary, medical needs, or special needs:_____________________________

 

_______________________________________________________________________

------------------------------------------------------------------------------------------------------------

Parental Permission Waiver

: My child(ren) and I are familiar with the Southbridge Public School’s Code of Conduct and agree that he/she will abide by all rules and regulations while attending the Cops N Kids Program.  I hereby release for myself, my heirs, administrators, and executors, any and all rights for claims and damages I may have against the Town of Southbridge, their agents, representatives or assignees, for any and all injuries suffered by me, my child or family while partaking in any activities connected with the program.  I understand that the program does not provide insurance coverage in the event of injury, and that it is my responsibility to provide insurance coverage for my child(ren).  I give permission for my child(ren) to receive emergency medical treatment in case of an emergency.  My child(ren) is/are physically and mentally fit to participate in all aspects of the program.  The Cops N Kids program prohibits inappropriate behavior and retains the right to remove any student that does not abide by the camp rules.

§         I give permission for my child to participate in all athletic and recreational activities provided at the camp.

§         I give my permission to the Southbridge Police Department to use pictures or videos of my child for media and promotional purposes. 

§         I give my child permission to be transported by bus/van to field trips designated by the Cops N kids program or other activities.

 

Parent/Guardian Signature____________________________________Date____________

 

Print Name___________________________________________________________________________

 

Use back of form for any additional comments, concerns or additional contact information.