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2. Childs Name*
4. Street Address*
5. City*
7. State*
8. Zip Code*
10. Date of Birth*
11. Telephone*
13. 
    
15. Parent/Guardian Email Address:
17. 
    
19. Shirt Size:
21. 
    
23. Emergency Contact Person*
24. Relationship*
26. Phone *
28. 
    
30. Does your child have any medical needs?*

    1. Yes
    2. No
32. If Yes Please Explain:
34. 
    
36. Family Physician Name:
37. Phone:
39. 
    
41. WAIVER
43. 
    I/We as parent(s) and/or guardian(s) hereby give approval for the above participant to participate in the Madison County Parks and Recreation Department Summer Playground Program. I grant permission to the Madison County Parks and Recreation personnel and the playground staff to authorize and obtain emergency medical care for the participant (my child).

    I/We agree to be financially responsible for any such medical care and agree to indemnify and
    hold harmless Madison County Tennessee , its employees, departments, agents, and assigns as to
    the cost of said care and also as to any and all actions and causes of action of participation in the Summer Playground Program. I/We understand that risk may exist during playground activities.
45. Print Parent/Guardian Name:*
47. 
    
49. Date:*
51. Signature: (email address)*
53. (Entering Your Email Address Represents Your Signature, and you are hereby giving permission for your child to participate in the Summer Playground Program, and you are agreeing to the above Waiver)
Leave This Blank:


55. Submit Submit and Print

* indicates a required field