Last Name ______________________________ First Name ______________________  MI _____
	

	Address	____________________________________________  Phone ________________________
	

	Birth Date ___________________________________________ Age on July 31, 2003 ________
	

	List any medial problems or prohibitions: __________________________________________
	

	Person(s) to notify in an emergency:_______________________ Phone: _________________
	

	Doctor to notify in an emergency:__________________________ Phone: _________________
	

Release
I, the parent/legal guardian of the registrant, a minor, agree that I hereby release, discharge and/or otherwise indemnify the East Kingston Recreation Department, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for Recreation Department activities against any claim by me or on behalf of the registrant as a result of the registrant's participation in East Kingston Recreation programs and activities and/or being transported to or from the same, which transportation I hereby authorize.

	Parent/Legal Guardian Name _________________________________________________
	
 
	Parent/Legal Guardian Signature ___________________________ Date ___________
	

Consent for Medical Treatment
As the parent or legal guardian of the above named player, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb, or well being of my dependent.

	Parent/Legal Guardian Name _________________________________________________
	
 
	Parent/Legal Guardian Signature ___________________________ Date ___________
	

Fee:    TBD    

Send form and fee to
     Bill LaCouture, 347-2534, 7 Woldridge Lane East Kingston, NH 03827.
     Phone: