Bedford Area Board of Parks And Recreation
PO Box 475
Bedford PA 15522
NAME___________________________________________________ GRADE ____________________
HOME PHONE _________________________ PARENTS WORK PHONE ____________________
BIRTH DATE _____________________________________________ AGE _______________________
Circle the program for which this registration is being made:
Swimming Baseball Softball Basketball Tennis Football
Golf Cheerleading Other ______________________________________
We, the parents of __________________________________, have seen that our child has been examined by a physician and is in sound physical health. We agree to provide accident insurance through our private company to cover our child as the Bedford Area Board of Parks and Recreation will carry no insurance. We are aware and understand there are certain assumed risks involved with our child’s participation in the above circled activity, and we will not hold the Bedford Parks and Recreation and/or any of the sponsoring agencies liable for any personal loss or injury that may occur. We are aware that the Bedford Board of Parks and Recreation does NOT sanction or sponsor any competition that involves children from outside the municipalities listed below.
Your signature is also needed for release of photo for use on the web site, no names will be listed. Please sign here if you do NOT want your child's photo used on the web site.
Declining photo release: Parent/Guardian Signature _______________________________________
Please circle area of Residency: Snake Spring Twp. Bedford Boro.
Cumberland Valley Twp. Rainsburg Boro.
Londonderry Twp. Manns Choice Boro.
Harrison Twp. Hyndman Boro.
Bedford Twp. Colerain Twp.
Parent/ Guardian Signature ______________________________________________
Webmaster Mary Dibert 5/7/2002