b"Registration FormGeneral InformationRETURN WITH PAYMENT TO: CONTACT US AT: For Office Use OnlyConcord Parks & Recreation Dept.Office:225-869014 Canterbury Rd. Fax: 225-8589Check #________CCCash SchlrshpConcord, NH 03301 E-mail: email@example.comMake Checks Payable to: City of ConcordWeb:www.concordparksandrec.comAmount:_______________Entered:________Adult First & Last NamePARENT/ AddressgUARDIANcONTAcT CityStateZipINFOHome PhoneWork PhoneCell PhonePlease PrintE-mailEmergency Contact Name Phone NumberPLEASE LIST PARTICIPANT INFORMATION AND THEIR COURSE CHOICESParticipant Information Date ofSex Child'sChild's Name of Class / Program Class Code FeeBirth ElementaryGradeFirst Name Last Name School (Sept.)List any special needs or medical conditions we should know about****PLEASE READ AND SIGN THE WAIVER BELOW**** ScholarshipTotal FeesIn Consideration of being permitted, at my specific request, for me or my child/ward to participate in theDonation activities of the City of Concord, New Hampshire Park and Recreation Department, we HEREBY RELEASE,Rounding up your pro-gram fee helps provide WAIVE, DISCHARGE, AND CONVENANT NOT TO SUE the City of Concord, its officers, employees, andfinancial agents, individually or in an official capacity for the City (all for purposes herein also referred to as Releasee)assistance to those other-from all liabilities, claims, actions, damages, costs orexpenses which we may have against any of thewise unable to afford theTotal Releasee arising out of or in any way connected to participation in the activity, including, travel to or from thecost of a program. Amountactivity, for bodily injury, death or property damage suffered by me/my child/ward before, during, or after said activity.I understand that this release and waiver includes any claim or action based on the negligence, action or inaction of any Releasee or otherwise.I HEREBY ASSUME FULL RESPONSIBILITY FOR ALLREFUND pROcEDURE - Refunds are issued only RISK OF INJURY OR PROPERTY DAMAGE due to the negligence of Releasee or otherwise while engagedwhen a class is cancelled by the Parks & Recreation in or as a result of the activity.In addition, I give my permission for the child(ren) to be treated by qualifiedDepartment or the participant enrolled in the program medical personnel in the event that the parent/guardian named below can not be reached at the phonehas a note from a physicians office stating they are numbers provided. All Parks & Recreation Department classes/events may be photographed. Participants maynot able to participate in the program because of a be photographed for City of Concord programs and promotions. medical condition. Refunds will not be issued if a class is cancelled due to inclement weather. If you feel your Signature (parent/guardian if participant isDate request for a refund was unfairly denied, there is an appeal process.Appeals must be in writing and sent tounder 18 years of age the Concord Parks & Recreation Department.REMEMBER THESE 5 EASY WAYS TO REGISTER!1 2 3 4Fax On-LineMail-In In-Person-AppointmentFax your registrationwww.concordparksandrec.com Mailcompleted registrationVisit us in at the Parks & to:(603)225-8589 and contactCustomers can sign-up via ourform & payment to:Recreation Office at 14 us at 603-225-8690 with on-line registration system atConcord Parks & Recreation Canterbury Rd to fill out your payment information www.concordparksandrec.com 14 Canterbury Rd., Concord,registration in person. CallNH 03301 603-225-8690 for appointment.2021 Summer & Fall Page 34www.concordparksandrec.com"