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Registration, Medical, and Waiver Form

REGISTRATION MUST BE COMPLETED ON THE PRIOR PAGE FIRST. FILLING THIS OUT ALONE DOES NOT SECURE YOUR CHILD A SPOT, IT PUTS YOU ON THE WAITLIST UNTIL PAYMENT IS RECEIVED.

COMPLETING REGISTRATION ON THE PRIOR PAGE WILL SECURE YOUR CHILD'S SPOT. ONCE THE REGISTRATION MAXIMUM IS HIT, ALL FORMS COMPLETED AFTER THAT WILL BE WAITLISTED.

Please fill out the following form
in order to participate in our activity.

ONE FORM PER CHILD, DO NOT COMBINE

Checks must be made payable to ‘Northern Lehigh Recreation’ and dropped off / mailed to the NLRA Office located at 7951 Center St., Slatington, PA, 18080. SPACE IS LIMITED.

Register online at www.NorthernLehighRec.org to secure your child’s spot. You print this form out to complete, if you do not want to fill it out online here, and return this waiver before camp begins.

Forms must be completed prior to participating and may be dropped off at the Washington Township Building.

Participant Name

Date of Birth

Age:

Last grade completed:

Parent Name

Phone

Address

Child's Doctor:

Insurance Carrier / Plan:

Preferred Hospital:

Policy #

Please list any current medications

Allergies:

Physical activity restrictions

Dietary restrictions

Medication Disclaimer The NLRA staff will not administer any medications. Your child will be responsible to self-administer medications, such as an inhaler, by him/herself. All medications that are brought to a program must be brought in their original packaging with the prescription intact. IF YOUR CHILD NEEDS REGULAR MEDICATION DURING PROGRAM HOURS, YOU WILL NEED TO CALL THE EXECUTIVE DIRECTOR TO MAKE ARRANGEMENTS BEFORE YOUR CHILD ATTENDS

I declare that the info I’ve provided is accurate & complete

Initials

Emergency Contact 1

Cell Phone

Home Phone

Work Phone

Emergency Contact 2

Cell Phone

Home Phone

Work Phone

I have read, understand and agree to all sections of this application. I hereby waive for myself and my child, the right to assert any claim arising out of injury to the child due to participation in any travel, recreation program, sport, or activity. I acknowledge that participation in the sport or activity authorized comes with certain risks which are hereby assumed. I relinquish any right which I or the child might otherwise have for payment of medical costs or other losses beyond whatever insurance I may have. I hereby authorize the director, staff and volunteers of the Northern Lehigh Recreation Authority to act for me according to their best judgment in any emergency requiring medical attention. I also give permission and understand that my child may be photographed during activities. The Northern Lehigh Recreation Authority may take photos and/or video of participants enrolled in the Programs, classes and special events. These photos and video clips may be used in commercial or non-commercial publicity. The Northern Lehigh Recreation Authority reserves the right to dismiss any member who does not show respect for the program, including but not limited to: property, equipment, policies, other participants and staff. Members who are dismissed will not be given a refund of their registration fee. THE NORTHERN LEHIGH RECREATION AUTHORITY ASSUMES NO RESPONSIBILITY FOR PERSONAL PROPERTY. By signing this application, I (we) hereby waive any and all claims against Northern Lehigh Recreation Authority. I understand that I am participating in recreation, education and cultural arts activities at my own risk. I hereby agree to reimburse The Northern Lehigh Recreation Authority for any lost or damaged equipment and/or property. Drugs and alcohol are prohibited at Northern Lehigh Recreation Authority programs and public park facilities. I understand that my registration fee is non-transferable and non-refundable. **By signing this form I hereby give permission for my son/daughter to participate in all aspects of the Northern Lehigh Bulldog Blast Summer Rec. Program**

Your Signature

Thanks for submitting!

Northern Lehigh Recreation Authority

Registration, Medical, and Waiver Form

CONTACT
US

Call or Text:
484-633-0093
Email:
nlrecauthority@gmail.com

VISIT
US

TELL
US

Registration, Medical, and Waiver Form

CONTACT US

Call or Text: 484-633-0093 Email:​ nlrecauthority@gmail.com

VISIT US

TELL US

CONTACT
US

Call or Text:
484-633-0093
Email:
nlrecauthority@gmail.com

VISIT
US

TELL
US