PROGRAM NAME           Winand Tae Kwon Do                                     SESSION DATES:                              COST:                 Participant's         Name_____________________________________ Home Phone: 410-________               First                     Last   Address ____________________________________________________________________           Street                     City                     ZIP E-mail ____________________________________________________________________ Emergency Contact:                           Participant DOB:_____________           Name _______________________________ Phone Number: 410- ___________ To the Parent: IT IS NECESSARY THAT YOU READ AND COMPLETE ALL INFORMATION FOR THE PROTECTION OF YOUR CHILD I hereby approve of the terms of this registration form/contract signed by me or my agent. I further agree that I will not hold any Recreation Council, the organizers sponsors, supervisors, volunteer leaders, or participants responsible for injuries or any unforeseen accident while participating in the above named activity, or while traveling to or from or being transported for this activity. 1. Are there any medical or other health factors that might affect your child's performance in this activity?           YES       NO   2. Is your child taking any medications that might affect his/her safety or performance in this activity?           YES       NO     NOTE: If the answer to Question 1 or 2 is yes, a medical release will be required ================================================================================ I hereby acknowledge that I have read and fully understand the above mentioned facts. I further certify that all answers, to the best of my knowledge, are true and correct. I hereby agree to abide by the rules and regulations as established by the Pikesville Recreation and Parks Council / Baltimore County Department of Recreation and Parks / Winand Elementary School PTA. ______________________   ___________     ______________________   ___________ Participant               Date           Parent                     Date ============================== FOR OFFICE USE ONLY ========================== Registration fee:$________ PAID BY [ ] Cash     [ ] Check (no.________)     [ ] Money Order Received by:______________   [ ] Other_____________