b"GReengeirsatlr aIntifoonr mFoartmionRETURN WITH PAYMENT TO: CONTACT US AT: For Office Use OnlyConcord Parks & Recreation Office:225-8690Dept. 14 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 in Sept.List any special needs or medical conditions we should know about****PLEASE READ AND SIGN THE WAIVER BELOW**** YouthTotal FeesScholarship Donation In Consideration for me and/or or my child/ward to participate in the sports and other activities of the City ofRounding up your program fee helps provide Concord, New Hampshire Park and Recreation Department, we HEREBY WAIVE AND RELEASE the City offinancial Concord, its officers, employees, and agents, individually or in an official capacity for the City (all for purposesassistance to thoseherein also referred to as Releasee) from all liabilities, claims, actions, damages, costs or expenses whichotherwise unable to affordTotal we may have against any of the Releasee arising out of or in any way connected to participation in the activity,the cost of a program. Amountincluding, travel to or from the activity, for bodily injury, death or property damage suffered by me/my child/ward before, during, or after said activity.In addition, I give my permission for the child(ren) to be treated by qualified medical personnel in the event that the parent/guardian named below cannot be reached at theREFUND PROCEDURE - Refunds are issued only phone numbers provided.when a class is cancelled by the Parks & Recreation I understand and agree that all Parks & Recreation Department classes/events may be photographed.I giveDepartment or the participant enrolled in the program permission to Parks and Recreation Department to use participants' photo for display or advertisement by thehas a note from a physicians office stating they are City of Concord, Parks & Recreation Department. not able to participate in the program because of a 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 4 EASY WAYS TO REGISTER!1 2 3 4Fax On-LineMail-In In-Person/Walk-InFax 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. Office NH 03301 hours are 8a.m.- 6:00 p.m."