City of Petersburg	City of Petersburg Recreation, Special Events, and Volunteerism - Registration Form	804 324-4015
Recreation, Special Events,			Payments for programs must accompany forms or they will not be processed.	www.petersburgva.gov/144/ and Volunteerism		Personal Information on Registration form may be given to Instructors, Coaches, or Volunteers	Parks-Leisure-Services 1937 Johnson Road	Enrollment is accepted on a first-come, first-served basis until the maximum number is reached or	Recreation@petersburg-
Petersburg Virginia 23805	until the specific program registration deadline has passed.	va.org	
Participant Name
(First & Last)	Age	Date of Birth
MM/DD/YY	Gender
M/F	Program Title	T-Shirt Size	Fee	

							
(For Youth Sports Only) Elementary School/Grade	Are you a City of Petersburg Resident?	YES	NO
($10 Non-Resident Fee Applies if No)	Fee Total	
Parent/Guardian F: Name:				Email Address:  		 Primary Phone #: (	)	Cellular Phone:			Work Phone: 	
Street Address:	City/State/Zip Code:  	
Email Address:	Are you interested in Coaching?	YES	NO	if YES, NAME: 			 Parent/Guardian M: Name		Primary Phone # (		)			Work Phone: 		 Street Address			City/State/Zip Code: 				

Emergency Contact: Name: _			Phone#:	Relation:			 Date of Last Physical Exam:_		Name of Family Physician:		Phone#: 		
Do any of the participants listed above have any medical conditions and /or concerns that our department should be aware of before participating in the program? (This should include, Food Allergies, Current Health Problems, Under Medical Care, Receiving Mental or Behavioral Services, Currently Taking Medication, Under- gone Surgery, Allergies, or Any other concerns you are aware of)	YES	NO	
IF YES, please list those conditions and concerns:  		
PRE-REGISTRATION EMAIL FORM TO:
RECREATION@PETERSBURG-VA.ORG		

Media Release: City of Petersburg periodically use electronic and traditional media (e.g., photographs, video, audio footage, testimonials) for publicity and infor- mational purposes. By my signature on this form, I acknowledge receipt of this document and give permission to City of Petersburg Departments and their design- ees to use such reproductions for informational and publicity purposes in perpetuity without further consideration from me. I understand that I will need to notify City of Petersburg if any changes to my situation occur that will impact this media release permission.

Participant Signature OR Parent/Guardian if participant is under 18 years	Date	Relationship to the Participant	
General Release of Liability and Assumption of Risk
I agree that my child’s participation in the program/activity/team assignment and any change therein will be pursuant to rules, I give permission for my child to travel with Parks and Leisure services on scheduled field trips. I further agree to indemnify, and hold the City of Petersburg harmless for an against any and all liability, for any injury, which may be suffered to my child arising out of and any way connected to his or her participation in this program/activity.
( If the Participant is under 18 and unable to sign, then the parents
Participant Signature	Date	signature will imply the parent ensures the participants understanding
and compliance)

 	 	
Parent/Guardian if participant is under 18 years	Date	Relationship to the Participant	
City of Petersburg Recreation, Special Events and Volunteerism Code of Ethics

I will display good sportsmanship and remember that recreation activities are supposed to be fun learning environment for myself, my child, and other partici- pants.
I will refrain from using profanity while participating in recreational activities.
Parents and participants will refrain from the use of tobacco, alcohol, and/or illegal substance while participating in recreational activities
I will show a positive attitude towards coaches, parents, officials, staff, and other participants at all times.
Participants are expected to remain with their team and/or group at all times during events, they are to be picked up and dropped off on time. Any guests of players or parents are to be held to the same standards as previously mentioned.
Violations of this code of ethics can result in but are not limited to, asking to leave an event, removal for the season, permanent dismissal from the prgram.
( If the Participant is under 18 and unable to sign, then the parents
Participant Signature	Date	signature will imply the parent ensures the participants understanding and compliance)	

Parent/Guardian if participant is under 18 years	Date	Relationship to the Participant	For Office Use

Staff Initial Complete Form