Carroll County Government - Department of Recreation and Parks

Summer 2008 Registration Form
Registrant's Last Name First M. I. Parent/Guardian (if applicable) Street Address City/Town State Zip Phone: Work Home email address Date of Birth Emergency Contact's Name Emergency Phone
Waiver of Liability: By my name below, I acknowledge that there are inherent risks and dangers associated with recreation programs, that Carroll County Bureau of Recreation does not provide any registrant medical or hospitalization insurance whatsoever, and therefore, I hold Carroll County Commissioners and their agents harmless from all claims of injury, damage, or loss which may result from my, or my child(ren)'s participation in the program/s listed below. Authorization for Use of Photographic Likeness: I agree to allow Carroll County Bureau of Recreation to take and utilize photographic images of the registered individual/s for the purpose of promotion and publicizing of the Bureau's programs and/or events. If I prefer to not allow the above registered individual/s to be photographed, I will call 410-386-2103 to register my request. Name Date Please enter your full name
Program Name	Program #	# Attending	Fee Per Person	Total
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Please choose only ONE of the following discount options
Early bird discount (pay in full by February 1st & deduct $5 per course)
Senior Discount (deduct 20% of class fee where eligible)
		GRAND TOTAL

After submitting registration info, please make a check payable to the Carroll County Commissioners and Mail to:
Carroll County Department of Recreation and Parks
300 South Center Street
Westminster, Maryland 21157