330 EAST JOHN STREET

BEDFORD, PA 15522

parksandrec@bedford.k12.pa.us

Phone 814-623-5693

REGISTRATION AND RELEASE FORM

NAME________________________________________________GRADE ____________________

ADDRESS ___________________________________________________________________________

E-MAIL ADDRESS_____________________________________________________________________

HOME PHONE ______________________________PARENTS WORK PHONE _____________________

BIRTH DATE _____________________________________________ AGE _______________________

If you were on a team last year, please list the team:____________________________________

Circle the program for which this registration is being made:

BASKETBALL BASEBALL CHEERLEADING FOOTBALL SOFTBALL VOLLEYBALL WRESTLING

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 activity circled above, 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.

Please circle area of Residency:

Bedford Borough Bedford Township

Colerain Township

Cumberland Valley Township

Harrison Township

Hyndman Borough

Londonderry Township Manns Choice Borough

Rainsburg Borough

Snake Spring Township

Parent/Guardian Signature: _________________________________________ Date: ______________

Print Name:__________________________________________________________________________

Signing this form verifies that you have received the Parents Code of Conduct and will abide by the rules listed.

$10.00 REGISTRATION FEE

PAID:___________________________________________