WEEKS AVAILABLE:
DECEMBER 20 – DECEMBER 23, 2010
DECEMBER 27 – DECEMBER 30, 2010
HOURS: 7:00A.M. – 6:00P.M.
FEE: $61.50 PER CHILD
REGISTRATION: DECEMBER 1, 2010
Closed December 25, 2010 and January 1, 2011
Community Services Department
“Wild N’ Winter” 2010
Registration Form
PARENT
NAME:
CHILDS NAME:
DOB:
ADDRESS:
HOME PHONE:
CITY:
EMERGENCY
CONTACT:
STATE:
Name:
WORK PHONE:
Phone:
FAMILY DOCTOR:
PHONE NUMBER:
FAMILY DENTIST:
PHONE NUMBER:
INSURANCE
CARRIER:
Please list the people that are allowed to come visit your child or sign them out of the program. If
someone wants to pick your child up and their name is not on this list, we will not release the child until
the parent/guardian is contacted.
All phone release requests will be accepted by the Recreation Technician II or the Recreation
Assistant only.
1.
6.
2.
7.
3.
8.
4.
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9.
5.
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10.
I have read and agree to the Program Policies and Fees:
Signature___________________________________
Date_______________________________________
“Wild N’ Winter” 2010
General Authorization Release Form
For (Minor Child)
MEDICAL CONSENT
I, ________________________, reside at __________________________, New Mexico, and am the
parent/guardian of a minor child who was born on _________19/20___ who resides with me
in my home who desires to participate in the Alamogordo Family Recreation Center Activities.
I authorize the Family Recreation Staff, City of Alamogordo, New Mexico, to consent on my behalf to any
examination, anesthetic, medical or surgical diagnosis and treatment as well as any hospital care which
he/she determines, on the advice of any physician or surgeon licensed to practice in the State of New
Mexico, should be rendered to my minor child in the event of any illness or injury resulting from my minor
child’s participation in the Alamogordo Family Recreation Center Activities.
LIABILITY RELEASE
I hereby request permission from the City of Alamogordo for ____________________________ (child’s name) to
be allowed to participate in the City-sponsored Turkey Week 2010. I understand and agree that the program
may involve a certain amount of physical danger and strenuous activity.
I affirm that I am the actual parent or legal guardian of the participant and am authorized to grant the
release contained in this agreement. I agree to indemnify, release and hold harmless the City of Alamogordo,
its officials, employees and agents from any and all damage and harm from all action, damages, claims or
demands of any kind which participant, his or her heirs, executors and assigns may have as a result of
being permitted to participate in this City sponsored activity.
PERMISSION FOR FIELD TRIPS
I will also allow the above named child to accompany the Alamogordo Family Recreation Center on programrelated field trips and events. I am aware that I will be informed of these field trips on a weekly basis.
I have read this release and understand its terms. I execute it voluntarily and understand that, in exchange
for participant being allowed to participate, I am waiving certain rights that participant and-or I may have.
____________________________________
Witness
____________________________________
Parent/Guardian Signature
____________________________________
Date Signed
____________________________________
Print Name
“Wild N’ Winter” 2010
Medications
Name of Medication _________________________________________________
Amount of Medication ________________________________________________
Dates to be given ____________________________________________________
Time(s) to be given each day __________________________________________
Parent/Guardian
Signature
Date
______________________________________________
Child’s Name
“Wild N’ Winter” 2010
Allergies
Name of Allergy (Food, Hay fever, etc.) ____________________________________
Medication needed ______________________________________________________
Dates to be given ______________________________________________________
Time(s) to be given each day _____________________________________________
Parent/Guardian
Signature
Date
_____________________________________________
Child’s Name
Parent Release Form for Media Recording
I, the undersigned, do hereby grant or deny permission to City of Alamogordo, Family Recreation Center to use the
image of my child, _________________________________, as marked by my selection(s) below. Such use includes the
display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child
for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos,
and digital images such as those on the City of Alamogordo, Family Recreation Center Web site.
 Deny permission to use my child’s image at all.
 Grant permission to use my child’s image in the following ways (mark all that apply):
 Limited usage: I want my child’s image used within the City of Alamogordo, Family Recreation Center setting
only (not in the larger community).
 Limited usage: I want my child’s image used for educational materials only (not marketing). This could be either
within City of Alamogordo, Family Recreation Center or in the larger community. One example of this could be
videos in parent education classes.
 Limited usage: I want my child’s image used on printed materials only (no digital or video use).
 Unrestricted usage: I give unrestricted permission for my child’s image to be used in print, video, and digital
media. I agree that these images may be used by City of Alamogordo, Family Recreation Center for a variety of
purposes and that these images may be used without further notifying me. I do understand that the child’s last
name will not be used in conjunction with any video or digital images.
Parent/guardian signature _________________________________
Date ________________
If you have questions, contact Youth Supervisor at (575) 439-4142 Est. 4406.