PLEASE COMPLETE THE SPECIAL NEEDS INFORMATION SHEET

CHILD'S NAME: __________________________________

LIABILITY RELEASE

__________________________________(Participant's Name) would like to participate in the Before/After School program of the Old Bridge Township Parks and Recreation Department.

The Old Bridge Township Parks and Recreation supervisors/leaders/aids/employees and/or volunteers agree to abide by all safety and procedural regulations required for the provision of safe programs and activities. I acknowledge the risks and potential risks inherent in participation in the Before/After School programs.

However, I feel the possible benefits to myself/my son/daughter/my ward are greater than the risk assumed. I, hereby, for myself and for ____________________________ (Participant's Name) waive and release all damages against Old Bridge Township and its representative personnel, and release all damages against Old Bridge Township for any and all injuries and/or losses I/my son/daughter/ward may sustain while participating in the Before/After School programs.

As a parent/guardian of the above participating child, I verify that he/she is in good physical health, has no special needs, and may participate in all activities of the center's program, except as noted.

Parent/Guardian signature ____________________________________________ Date: __________________________

Telephone number (______) ____________________ (work/home)

Insurance Co. _______________________________________ Identification# ___________________________________

Group# ______________________