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Step One

Middlesex County Parks & Recreation
P.O Box 428
Saluda, Va 23149
804-758-0057
Activity Registration Form
Adult Section
Name
Email Address
Address
City
State
Zip Code
Phone Number
Fax Number
Participant Information
Activity
Participants Name:
Participants Name:
Participants Name:
Sex
Age
Birthday
Fee:
Discount
Amount Paid:
Subtotal
Out Of County
Balance
Receipt Number
Form of Payment (Cash)
Check #
Money Order
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Step Two

Assumption of Risk and Release
In agreeing to participate in the program, as an adult participant or as a parent or guardian of a participant, I and/or the participant do hereby affirm that the general health of the participant is good and that the participant is not adversely affected by exercise and that the participant is capable of performing and activity of this nature. In consideration of participating in this activity, I and/or the participant do hereby assume all risk of and injury to the participant and will indemnify and hold harmless, from any and all liability, action, cause of actions, claims, and demands of every kind of nature whatsoever that I and/or the participant have or which arise for in connection with my participation in this activity, the County of Middlesex, Virginia, the Middlesex County Board of Supervisors, the Middlesex County Department of Parks and Recreation, the Middlesex County School Board, and all their officers, agents, employees, staff, volunteers, and successors. It is likewise assumed and agreed that the participant will wear proper clothing and protective equipment during the activity and that it is the responsibility of the participant or parent or guardian to make sure the criteria is met. I grant permission to transport the participant to and from the even when required and hold harmless those assigned to transport. I also agree to allow transportation of the participant to the nearest physician or hospital for medical treatment and agree to allow for immediate first aid to the injured participant when deemed necessary.
I hereby give my permission to have my child photographed for use in the local paper.
I also give my permission
1. Give Permission
I also do not give my permission
1. Do Not Give Permission
I hereby give my permission to have my child photograph on the Middlesex Parks and Recreation Website
I also give my permission
1. Give Permission
I also do not give my permission
1. Do Not Give Permission
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature

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