Registration and Acknowledgment of Risk Form

All information is for Parks & Recreation use only.

Village of Archbold Department of Parks & Recreation
300 N. Defiance Street
Archbold, OH 43502

* required field
** required field if under 18

FINANCIAL ASSISTANCE IS AVAILABLE TO QUALIFIED INDIVIDUALS FOR ALL PROGRAMS. PLEASE CONTACT PARKS & RECREATION FOR MORE INFORMATION.

Program Name*

Participant's Name*

Street Address and City*

Zip*

Phone*

Work Phone

Email* (for updates, etc.)

If the participant is under 18 years old please fill out the information in the area below:

Date of Birth**

Parent's Name**

Grade**

School Attending**

T-Shirt Size

Emergency Contact 1*

Phone*

Emergency Contact 2*

Phone*

Doctor*

Phone*

Dentist*

Phone*

Hospital Preferred*

Phone*

Special Limitations/Conditions/Allergies*

Yes*I recognize that the Village of Archbold, any of its co-sponsors including other entities, their employees or agents, assume no responsibility for myself or my child. I will assume all risks that may arise from this participation. I also hereby waive any claims against the Village, its co-sponsors, their departments, officers, employees or agents for any injuries or loss that may arise form this participation. This release includes off-site transportation of program participants to and from Village facilities and related field trips and programmed activities. I acknowledge I retain the right to assert any claims that arise from the gross negligence or gross misconduct of the Village of Archbold or any co-sponsoring entities, their officers, employees or agents.

Yes**By clicking this box, I certify that my minor child and I have viewed the Lindsay’s Law Video.

Yes**By clicking this box, I certify that I have read and acknowledge receipt of the Lindsay’s Law information sheet.

Yes**By clicking this box, I certify that I have read and acknowledge receipt of the Ohio's "Return to Play Law" information sheet.

Yes NoWe would like to help out a child. We have enclosed additional money to be used for the registration of a child in need of assistance.