Baltimore County Department of Recreation & Parks
Reisterstown Area Recreation & Parks Council

Karate Registration Form
  Athlete Info:
 
LAST NAME FIRST NAME BIRTH DATE AGE
STREET ADDRESS CITY STATE ZIP HOME PHONE
Parent/Guardian Info:      
MOTHER'S LAST NAME FIRST NAME HOME PHONE OTHER PHONE E-MAIL
FATHER'S LAST NAME FIRST NAME HOME PHONE OTHER PHONE E-MAIL
Emergency Contact Info:      
 
LAST NAME FIRST NAME HOME PHONE OTHER PHONE  
Physician Info:    
Registration Fee: $25 for 1 night/week for a 10 week session.
or   $40 for 2 nights/week for a 10 week session.
LAST NAME FIRST NAME PHONE  
       
   

 

MEDICAL HISTORY

1. Does the registrant have any physical, emotional, psychological or social disorders, handicaps, diseases,
    disabilities or  allergies?     Yes        No

2. Is the registrant taking any medication that might affect his/her safety?   Yes        No

3. Does the registrant require any special accommodations due to a disability?    Yes        No

3. If "Yes" to any question above, please describe:

4. If question 1 or 2 was checked "Yes," I agree to provide a medical release prior to registrant engaging in this
    activity if requested by the Reisterstown Area Recreation & Parks Council.     Yes 

 

LIABILITY DISCLAIMER

I/We assume all risks incidental to the conduct of the program activities and transportation to the same and do hereby release, absolve and acquit the Reisterstown Area Recreation & Parks Council, its organizers, supervisors, managers, coaches, sponsors, volunteers and other personnel agents, Baltimore County Department of Recreation & Parks and its employees from any liability whatsoever in regard to the same, and from any claim for damages of whatever nature arising out of the activities conducted including, but not limited to, injuries received at the designated sites of activities or practices.

PERMISSION TO ADMINISTER FIRST AID

Permission is hereby granted for any coach, manager, leader, attendant, assistant coach or council official to authorize first-aid, as well as such medical treatment as may be deemed appropriate by a licensed physician for any illness or injury incurred or sustained by registrant while engaged in Reisterstown Area Recreation & Parks Council activities.

PARENT/GUARDIAN CODE OF CONDUCT

Recognizing that parents/guardians are the most important role models for their children, and recreation/amateur athletics help children develop a sense of teamwork, self-worth and sportsmanship, we encourage our children to play by the rules, and respect the rights of others. We understand it is just as important on the athletic field/gym as it is in the home to enforce rules of play/behavior and set standards as necessary for both athletics and life. We will at all times encourage our children to play by the rules, respect the game officials' decisions, and will not publicly criticize players, coaches, or game officials during or immediately after an athletic contest/event.

As a parent, I acknowledge the importance of being involved in my child's recreational activities. I will introduce myself to my child's volunteer coach/leader and will exchange pertinent contact information with them. I will know who is transporting my child to and from any recreational activity. I will know my child's schedule - practice days, dates and schedules. I will help ensure a drug, alcohol and tobacco-free environment for my child. I will place the emotional and physical well-being of my child ahead of any personal desire to succeed. I will provide support for coaches and leaders working with my child to provide a positive, enjoyable experience for all. My child & I will treat other participants, spectators and officials with respect regardless of race, sex, creed or ability.

I hereby state that my child is in good health and able to participate in this program. I further acknowledge that I have and fully understand the above-mentioned facts, including the Parents' Code of Ethics and the fact that Baltimore County Department of Recreation and Parks does not provide background checks on volunteers. I certify that all answers, to the best of my knowledge, are true and correct.

I have read, understand and agree to the above and do hereby testify to the accuracy of the above information and will comply with the registration provisions indicated above.

_________________________________________________________________________
 Signature Parent/Guardian or Participant (if over 18)                                                                                      Date

I hereby agree to abide by the rules and regulations as established by the local Recreation & Parks Council, I further agree that when I leave this activity or at its' completion, I shall return any and all equipment and uniforms issued to me.

_________________________________________________________________________
 Signature of Registrant                                                                                                                                Date

 

Reisterstown Karate, PO Box 302 Timonium, MD 21094
410-887-1142       fax: 410-517-2123        email ShihanNusz@yahoo.com