Village of Croton-on-Hudson
Recreation & Parks Department
Mail-in Registration Form/Release Form
Please print and use a separate form for each person. When mailing a form, please send separate checks for each program. All information must be completed or registration will not be accepted.
Participant’s
Name_____________________ Date of Birth ________ Grade____
Address___________________________________________
Parent’s Name____________________________________________
(if under 18)
Home Phone__________________WorkPhone_________________
Emergency Name & Phone__________________________________
Activity # Section # Program Day Fee
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Total Due______________
I am enrolling myself/my child in programs offered by the Croton Recreation and Parks Department/Village of Croton-on-Hudson. In so doing, I hereby waive, release and discharge the Village of Croton-on-Hudson, its employees and agents from any liability for injury to person or property that may arise from my/my child participating in these programs. I hereby also state that I will have health insurance for myself/my child in effect during the time I am engaging in any activities offered by the Croton Recreation Department, its agents or employees. I agree to indemnify and hold harmless the Village of Croton-on-Hudson for any damages or injuries resulting from my or my child’s intentional or negligent conduct.
_____________________________________________ ____________
Participant’s Signature (parent or guardian if under 18) Date
Registration may be done using this “Mail-in Registration Form”. Please be sure to complete all information, sign and enclose check(s) for the proper amount made payable to “Croton Recreation and Parks” and mail to Municipal Building, 1 Van Wyck Street, Croton-on-Hudson, NY 10520.
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