PRINCETON SPECIAL SPORTS & PROGRAMS - (PRINCETON, NJ)

ADAPTIVE HOLIDAY COOKIES & COCOA - DECEMBER 15, 2024

Sign up here to celebrate the holidays with games and crafts at our Adaptive Holiday Cookies & Cocoa from 1:00 to 2:30 on December 13. Medical information is required so it can be provided to emergency medical personnel if necessary.

All requested information must be provided. Incomplete registrations cannot be processed.

* PARTICIPANT'S FIRST NAME:

* PARTICIPANT'S LAST NAME:

* FULL ADDRESS (STREET AND TOWN):

* DATE OF BIRTH:

* PHONE:

* EMAIL ADDRESS:

* PHYSICAL, NEUROLOGICAL, COGNITIVE DIAGNOSIS(ES):

ALLERGIES::

* MEDICATIONS (LIST ALL):

* PARENT/GUARDIAN NAME:

* PARENT/GUARDIAN CELL PHONE:

OTHER EMERGENCY PHONE:

I AM LEGALLY RESPONSIBLE FOR THE PARTICIPANT NAMED ABOVE. I CONFIRM THAT PARTICIPANT DOES NOT HAVE ANY PHYSICAL, COGNITIVE, PSYCHOLOGICAL, OR OTHER CONDITION THAT WOULD PREVENT OR IMPAIR HIS/HER/THEIR PARTICIPATION IN THIS ACTIVITY. I ACKNOWLEDGE THAT I MUST INFORM A PROGRAM REPRESENTATIVE IMMEDIATELY IF PARTICIPANT'S CONDITION CHANGES AT ANY TIME DURING, AND IN A WAY THAT IMPACTS, HIS/HER/THEIR PARTICIPATION IN THIS ACTIVITY. I AGREE THAT PARTICIPANT WILL COMPLY WITH ALL ACTIVITY RULES, REGULATIONS, SAFETY PROCEDURES, AND INSTRUCTIONS. I ALSO UNDERSTAND THAT THE USE OF INAPPROPRIATE OR ABUSIVE LANGUAGE OR CONDUCT MAY CAUSE PARTICIPANT AND/OR PARTICIPANT'S PARENT OR GUARDIAN TO BE PROHIBITED FROM ATTENDING PSS PROGRAMMING.

I ACKNOWLEDGE THAT PARTICIPATION IN THIS ACTIVITY CARRIES A RISK OF SERIOUS INJURY OR ILLNESS. I VOLUNTARILY ASSUME ALL RISK AND RESPONSIBILITY, FINANCIAL AND OTHERWISE, FOR ANY INJURY OR ILLNESS NO MATTER WHAT THE CAUSE, INCLUDING, BUT NOT LIMITED TO, SARS-CoV-2, COVID-19, MIS-C, OR ANY OTHER PANDEMIC ILLNESS ? THAT MAY OCCUR AS A RESULT OF PARTICIPATION IN THIS ACTIVITY. I UNDERSTAND THAT THIS ACTIVITY IS NOT STAFFED WITH MEDICAL PERSONNEL AND AUTHORIZE THIS ACTIVITY'S ADULT STAFF TO CONSENT TO MEDICAL TREATMENT IN THE EVENT OF AN EMERGENCY. I CONFIRM THAT I HAVE PROVIDED ACCURATE AND COMPLETE INFORMATION, INCLUDING PARTICIPANT'S DIAGNOSIS(ES), MEDICATION(S), AND ALLERGY(IES) AS APPLICABLE, IN THIS REGISTRATION AND AGREE THAT THIS INFORMATION MAY BE PROVIDED TO EMERGENCY MEDICAL PERSONNEL AS MAY BE NECESSARY.

I CONSENT TO THE USE OF THIS PARTICIPANT'S PHOTOGRAPH IN SOCIAL MEDIA AND OTHER PUBLICATIONS RELATING TO PRINCETON SPECIAL SPORTS & PROGRAMS, THE PRINCETON RECREATION DEPARTMENT, THE MONTGOMERY TOWNSHIP RECREATION DEPARTMENT, OR TOWN SQUARE AT PRINCETON . I UNDERSTAND THAT PARTICIPANT'S NAME WILL NOT BE PUBLISHED WITHOUT THE PERMISSION OF AN ADULT WITH THE AUTHORITY TO SO CONSENT.

I HAVE BEEN INFORMED THAT THE ABILITY TO RECOVER DAMAGES FROM PUBLIC ENTITIES SUCH AS THE PRINCETON RECREATION DEPARTMENT AND THE MONTGOMERY TOWNSHIP RECREATION DEPARTMENT, , AS WELL AS THEIR OFFICERS, AGENTS, SERVANTS, AND EMPLOYEES, MAY BE LIMITED BY THE PROVISIONS OF THE NEW JERSEY TORT CLAIMS ACT, N.J.S.A. 59:1-1, et seq. REGARDLESS, I KNOWINGLY AND VOLUNTARILY RELEASE AND HOLD HARMLESS PRINCETON SPECIAL SPORTS INC. d/b/a PRINCETON SPECIAL SPORTS & PROGRAMS, THE PRINCETON RECREATION DEPARTMENT, THE MONTGOMERY TOWNSHIP RECREATION DEPARTMENT, AND TOWN SQUARE AT PRINCETON, AND THE OFFICERS, TRUSTEES, DIRECTORS, SPONSORS, BUDDIES, COACHES, VOLUNTEERS, UMPIRES, REFEREES, EMPLOYEES, AGENTS, ATTORNEYS, TRAINERS, GOVERNING BODIES OR ENTITIES, PROGRAM PARTNERS, AND REPRESENTATIVES OF EACH OF THEM (COLLECTIVELY PROGRAM SPONSORS) FROM ANY AND ALL CLAIMS OF WHATEVER NATURE, AND AGREE NOT TO BRING ANY LAWSUIT OR LEGAL ACTION AGAINST THE PROGRAM SPONSORS OR ANY OF THEM FOR ANY REASON WHATSOEVER.

I AGREE TO THE ABOVE *

* PARENT/GUARDIAN SIGNATURE:

* indicates required fields