Charter Township of Orion

Parks & Recreation Department

Program Registration Form

Parent/Adult Name:

Address:

City:

State:

Zip Code:

Home Phone:

 (      )

Emergency Phone:

 (      )

Daytime Phone:

 (      )

Last Name

First Name

Birthdate

Gender

Program Name

Fee

Shirt Size (Please Circle):

Total Enclosed:

LIABILITY WAIVER FOR PARTICPANT: As a participant (or as a parent of a participant under 18 years of age) in the Orion Township Parks & Recreation Program(s) I recognize and acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any injuries, including death, damages, loss which I sustain as a result of participating in any and all activities connected or associated with the program(s). I do hereby fully release and discharge the Charter Township of Orion, their officers, agents, volunteers, and employees from any and all claims from injuries, including death, damages or loss which I may have or which may occur to me on account of my participation in the program(s). I further agree to indemnify and hold harmless and defend the Charter township of Orion, their officers, agents, volunteers, and employees from any and all claims resulting from injuries, including death, damages and losses sustained by me and rising by me and arising out of, connected with, or in any way associated with these program(s). Photographs may be taken at certain Recreation Department activities and unless the department receives signed, written objections, photos may be reproduced for publication.

I FULLY READ & UNDERSTAND THE FOREGOING

Make checks payable to: ORION TOWNSHIP.

Return in person, drop box, or by mail to:

Orion Township Parks & Recreation

2525 Joslyn Rd.

Lake Orion, MI 48360

Office Hours: Monday - Friday, 8:30 a.m. - 4:30 p.m.

Phone: (248) 391-0304, ext. 143; Fax: (248) 391-0332

Applicant's Signature

IF UNDER 18 YEARS, PARENT OR GUARDIAN SHALL SIGN

Date

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