Community Center Participant Registration Complete the participant registration form for the City of Salisbury Community Centers. All participants must register in order to participate in activities and events. SECTION 1: Participant InfoParticipant Name First Last Address* Street Address City State / Province / Region ZIP / Postal Code Age*Date of Birth*Gender*MaleFemalePrefer Not to SayEthnicity*Black / African AmericanHispanic / LatinoWhite / CaucasianNative American / American IndianAsian / Pacific IslanderProvide any additional or medical information that the Staff should be aware that may impact participation in an activity or event?SECTION 2: Parent/Guardian InfoParent/Guardian Name (completing the registration form)* First Last Phone Number*Email*SECTION 3: Emergency Contact InfoEmergency Contact Name* First Last Phone Number*Relationship to Participant*Parent/GuardianFamily MemberRelativeFamily FriendSECTION 4: Waiver and SignatureElectronic Signature (Read waiver and fill in name)* WAIVER: In consideration of the execution of a similar contract by all persons participating in this activity/program, the participant does hereby agree to abide by all rules. The undersigned do hereby expressly stipulate and agree to indemnify and hold forever harmless the City of Salisbury, its agents, officers and employees, against loss from any and all claims, demands, or actions in law or equity that may hereafter at any time be made or brought by the participant listed below, or by anyone on behalf of said participant for the purpose of enforcing a claim for damages on account of any injuries received or sustained by the participant arising out of his participation in the program. In signing this Release and Hold Harmless Agreement, each of the undersigned hereby acknowledges and represents that they are aware of the risks and hazards inherent in participating in the activity including exposure to the potential risk of concussion. No insurance covering accident or injury has been provided for participants. Arrangements for any such insurance would have to be made individually by the undersigned.