Parks & Rec Registration Parks & Rec Registration Form Participant First & Last Name * Participant Phone Number * Address * City * Zip Code * Gender * Male Female Date of Birth * Format: MM/DD/YYYY Age * Special Needs – contact the Parks & Rec Dept & advise instructor/coach Grade (if participant is a minor) School (if participant is a minor) I am a: * Town of Mukwonago Resident/Tax Payer Village of Vernon Resident/Tax Payer Non-Resident Email Address * Parent/Guardian First & Last Name (if participant a minor) Parent/Guardian First & Last Name (if participant a minor) First First Last Last Emergency Contact First & Last Name * Emergency Contact First & Last Name First First Last Last Emergency Contact Phone Number * Activity Name * Activity Number * Activity Name Activity Number Activity Name Activity Number Are you willing to head coach? Yes No Head Coach Name Head Coach Phone Number Head Coach Email IF REGISTERING FOR A YOUTH SPORT, PLEASE COMPLETE THE FOLLOWING INFORMATION ALSO THE PARENT & ATHLETE AGREEMENT (below) MUST BE SIGNED ELECTRONICALLY BY BOTH A PARENT & ATHLETE TO PARTICIPATE Friend Request ONLY one friend or sibling request per participant. Please pre-arrange friend match up, you must request each other with your original registration form. Soccer Uniform Size Please select, if applicableYouth Medium (10-12)Youth Large (14-16)Adult SmallAdult MediumAdult LargeAdults X-Large NEW SOCCER PARTICIPANTS must purchase a uniform (one time) Cost: $35.00 T-Shirt Size Please select, if applicableYouth Medium (10-12)Youth Large (14-16)Adult SmallAdult MediumAdult LargeAdult X-Large i.e. baseball/basketball/flag football/volleyball – cost included in registration fees Note any known practice day conflicts that you know of (i.e. Tuesday, Wednesday) we cannot guarantee honoring them, but every effort will be made. Total Fees * After 3:30pm on registration dead- line date APPLY $12 LATE FEE Late Fee per participant Checks payable to: Town of Mukwonago PLEASE READ THE FOLLOWING AND SIGN I am aware of and understand that there may be potential risks inherent with participation in any recreation activity, and that the Town of Mukwonago and the Town of Mukwonago Parks & Recreation Department are not liable for any injury that may occur. The Town of Mukwonago and the Town of Mukwonago Parks & Recreation Department do not provide accident insurance and cannot assume responsibility for injury to any participants in its recreation programs. I give my permission to the Town of Mukwonago Parks & Recreation Department to take action (call emergency vehicles, transport to doctor/hospital) for myself or my child if immediate medical attention is required due to accident or illness while under his/her/their supervision. *My/our electronic signatures on this form are the legally binding equivalent to my/our handwritten signature: * Agree Signature * Adult Participant OR Parent/Guardian (if participant under 18 years of age) Date * Format: MM/DD/YYYY PARENT & ATHLETE AGREEMENT — MUST SIGN TO PARTICIPATE IN LEAGUE SPORTS ONLY League Sports — for Baseball/Softball/T-ball/Soccer/Basketball/Flag Football/Volleyball “Know your Concussion ABCs” information on our website www.townofmukwonago.wi.gov. Concussion Law, Wis. Stat. sec 118.293 Athlete Agreement: I have read the Athlete Concussion and Head Injury Information and understand what a concussion is and how it may be caused. I understand the importance of reporting a suspect-ed concussion to my coaches and my parents or guardian. I under- stand that I must be removed from practice or play if a concussion is sus- pected. I under-stand that I must provide written clearance from an appro- priate health care provider to my coach before returning to practice/play. I understand the possible consequence of returning to practice/play too soon and that my brain needs time to heal. Athlete Signature Date Format: MM/DD/YYYY Parent Agreement: I have read the Parent Concussion and Head Injury Information and understand what a concussion is and how it may be caused. I also understand the common signs, symptoms, and behaviors. I agree that my child must be removed from practice/play if a concussion is suspected. I understand that it is my responsibility to seek medical treatment if a suspected concussion is reported to me. I understand that my child cannot return to practice/play until providing written clearance from an appropriate health care provider to his/her coach. I understand the possible consequences of my child returning to practice/play too soon. Parent Signature Date Format: MM/DD/YYYY Assume you are registered in all the programs you have signed up for. You will only be notified if a program is full or cancelled. TO FINISH REGISTRATION, PLEASE CLICK “SUBMIT” BELOW TO CONTINUE TO STEP 2: PAYMENT PROCESSING. YOU ARE NOT REGISTERED UNTIL PAYMENT IS RECEIVED. Submit If you are human, leave this field blank.