Junior Program Registration – Rollingwood Athletic Club

Participant’s Name *

DOB: *

Parent/Guardian Name(s) *

Phone *

Email *

Parent/Guardian Name(s) *

Phone *

Email *

Address *

City *

State *

Zip *

Age

7-1011-1314 & Up

Program

AquaticsFitness

Time

SeptemberOctoberNovember

Payment Method

Charge to RAC Member AccountContact me for payment information

*Your reservation is not complete until payment has been made. You can contact us at (916) 988-1727

Emergency Contact *

Phone *

Emergency Contact

Phone

Allergies

Medications to be administered in case of emergency

Behavioral/Emotional/Physical conditions we need to know about

Release, Waiver of Liability & Consent for Medical Treatment

In the event of illness or injury arising out of my child’s participation in RAC Summer Camp, I give consent and authorization for (1) the administration of emergency first aid care and treatment at the scene of an emergency by employee at RAC, or (2) the administration of any treatment deemed necessary by a licensed physician, and (3) the transfer to a hospital reasonably accessible.

I understand and agree that my child’s participation in the RAC After School Programming is voluntary. I further understand and agree that participation in the RAC After School Programming is at my child’s or my own risk and that Rollingwood Athletic Club is not responsible for any incidents, injuries, or loss of property that may occur.

In the event of an emergency if I cannot be reached, I give permissions to RAC staff to obtain medical treatment for my child. I hereby release RAC, its staff and employees from claims of damages while participation in RACs After School Programming. I have carefully read this entire consent for Medical Treatment and Waiver of Liability and I fully understand its contents.

I have signed this form of my own free will and I agree to be legally bound to it.

By signing and initialing below, I agree to the following terms and conditions

Behavior Policy: Participants must abide by all rules of RAC. Each participant must behave appropriately towards other juniors, members and staff at all times. Inappropriate behavior may result in dismissal from the program without a refund.

Photography/Video Policy: I give Rollingwood Athletic Club permission to print and publish my child(s) picture for promotional purposes. I understand that I will not receive compensation for my child(s) picture/video.

all agreements must be checked

Child(ren)'s Name *

Parent/Guardian Signature *

Date *