Pelham Parks and Recreation

6 Village Green, Pelham, NH 03076                      Phone: 635-2721           Fax:  508-3094      Email:  recreation@pelhamweb.com

CO-ED ADULT VOLLEYBALL

Release and Registration Form 2009-10

Participant ___________________________________ DOB                                           

Address:  _______________________________________________________________

                    Street                                                      City                 State                Zip

Phone:  _________________               Work Phone:  ____________________________

Cellphone:  ________________________

Can you participate in exercise?  __________ Restrictions:  _____________________

Email address:   _________________________________________________________

Allergies:  _____________________________ Medication allergies:  ______________

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:  _______________________

Phone:  ________________________________

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, it’s employees, agents, representatives, coaches, volunteers 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.

________________________________________________________________________

Date:                                                               Signature of participant

Cost:  There is no cost for this program but a signed form is required.  Program is scheduled each Monday evening at Pelham Elementary School at 7:00 p.m. beginning October 7, 2009 through late May/early June.  Participants must be at least 18 years of age.  Supervisor:  Jeff Jameson.  Please call 635-2721 with any questions or email recreation@pelhamweb.com.  Program subject to cancellation or changes due to school schedules.  Thank you!