BEDFORD RECREATION DEPARTMENT REGISTRATION FORM
Recreation Fax #: (781) 687 - 6156

Name:__________________________Sex: M/F Home Phone:(______)_____________
Address:_______________________ Grade Fall 2007: __ Age__ Birthdate__________
Mother Work #:(______)__________________ Father Work #:(______)____________
Mother Cell Phone:_______________________ Father Cell Phone:________________
E-mail Address(es): _____________________________________________________
Emergency Name & # (other than parent):________________(_______)____________
Special Needs/Concerns:_________________________________________________
Contribution to the Neighbors Helping Neighbors Fund: $_______ Parent Coach/Chaperone?_______
Program:__________________________ Day:________ Time:________ Fee:______
Program:__________________________ Day:________ Time:________ Fee:______
Program:__________________________ Day:________ Time:________ Fee:______
Uniform size: Shirt:_____ Shorts:____ Travel Soccer Shirt#:____ Pymt type: ___cash ___check ___MC/Visa
MC or Visa #:____________________________________ Exp. Date:_____________
I do hereby consent to my minor child(ren)’s/my own participation in the program(s) into which I am enrolling, run by the Bedford Recreation Department, and do forever RELEASE, acquit, discharge and covenant to hold harmless the Town of Bedford, and the Town of Bedford Recreation Department and all of its employees and agents from any and all actions, causes of action, and claims, including, but not limited to negligence, on account of, or in any way growing out of, directly or indirectly, all known and unknown personal injuries or property damage occurring while participating in any part of the program(s), wherever it occurs, which my minor child(ren)/I may now or hereafter have and as the parent of said minor(s), also any and all claims, actions, causes of actions, including, but not limited to negligence which said minor has or hereafter may acquire, either before he/she or after he/she has reached his/her majority resulting from his/her participation in the Town of Bedford Recreation Department’s program.
Date:_______________ Signature:______________________________________ (parental if participant is under 18 years of age)

BEDFORD RECREATION DEPARTMENT REGISTRATION FORM
Recreation Fax #: (781) 687 - 6156

Name:__________________________Sex: M/F Home Phone:(______)_____________
Address:_______________________ Grade Fall 2007: __ Age__ Birthdate__________
Mother Work #:(______)__________________ Father Work #:(______)____________
Mother Cell Phone:_______________________ Father Cell Phone:________________
E-mail Address(es): _____________________________________________________
Emergency Name & # (other than parent):________________(_______)____________
Special Needs/Concerns:_________________________________________________
Contribution to the Neighbors Helping Neighbors Fund: $_______ Parent Coach/Chaperone?_______
Program:__________________________ Day:________ Time:________ Fee:______
Program:__________________________ Day:________ Time:________ Fee:______
Program:__________________________ Day:________ Time:________ Fee:______
Uniform size: Shirt:_____ Shorts:____ Travel Soccer Shirt#:____ Pymt type: ___cash ___check ___MC/Visa
MC or Visa #:____________________________________ Exp. Date:_____________
I do hereby consent to my minor child(ren)’s/my own participation in the program(s) into which I am enrolling, run by the Bedford Recreation Department, and do forever RELEASE, acquit, discharge and covenant to hold harmless the Town of Bedford, and the Town of Bedford Recreation Department and all of its employees and agents from any and all actions, causes of action, and claims, including, but not limited to negligence, on account of, or in any way growing out of, directly or indirectly, all known and unknown personal injuries or property damage occurring while participating in any part of the program(s), wherever it occurs, which my minor child(ren)/I may now or hereafter have and as the parent of said minor(s), also any and all claims, actions, causes of actions, including, but not limited to negligence which said minor has or hereafter may acquire, either before he/she or after he/she has reached his/her majority resulting from his/her participation in the Town of Bedford Recreation Department’s program.
Date:_______________ Signature:______________________________________ (parental if participant is under 18 years of age)