Pelham Parks and Recreation

6 Village Green, Pelham, NH 03076         Phone: 635-2721       Fax: 508-3094

MEN’S PICKUP BASKETBALL

2008 - 2009

Release Form

Email recreation@pelhamweb.com with any questions.

Participant ___________________________________ DOB ____________ Age ______

Address:  _________________________________________ Phone ________________

              Street                                               Town                              State          Zip                     Include area code

Can you participate in strenuous exercise?  ______  If not, what are your      

restrictions:  ______________________________________Cellphone:  ____________________

Email address please:  ____________________________________________________________

Any other information to help meet your needs:  ______________________________________

______________________________________________________________________________

In case of emergency contact:  Give the name of responsible adult who will be available at telephone listed during time of event.

Name ____________________________________________  Relation  ____________________

Address _____________________________________________Phone ____________________

Name of Medical Insurance:  _______________________________________ # _____________

I assume all of the risks normally incidental to the nature of this activity, including risks, which are not foreseeable.  I will follow rules and regulations provided by those in charge.  I, the undersigned, hereby agree to release, indemnify, save and hold the Town of Pelham, the Parks and Recreation Advisory Board, Parks and Recreation, its employees, agents, representatives, coaches, volunteers and referees from any and all liability, actions, causes of action, debts, claims or demands of any kind and nature whatsoever which may arise by or in connection with participation in the above activities.

______________________________________________________________________________

Signature of participant                                                                           Date

*Please make check payable to Town of Pelham.  Cost for registration is $35, open to residents only.  Pickup games are each Tuesday/Thursday nights 7:00 – 9:30/10 p.m., beginning 9/16/08 through the end of the school year.  Use of Pelham Elementary school gym is subject to school needs and school closings.  Our supervisor is Bob Charette.  Please check in with him.

For office use:  No cash policy in effect.  Checks or money orders only; charge cards in person.

________________ Fee paid   __________________ Date  _________________ Check No.