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2. PARTICIPANTS NAME*
   ALL CHILDREN MUST HAVE A BIRTH CERTIFICATE ON FILE WITH OUR DEPARTMENT
3. ACTIVITY*
5. CONFIRMATION NUMBER*
   YOU GET A CONFIRMATION NUMBER BY PAYING THROUGH OUR ONLINE PORTAL. YOU MUST PAY BEFORE FILLING OUT THIS FORM
6. BIRTH DATE*
   BIRTH DATE
7. GENDER*

   1. MALE
   2. FEMALE
9. PHONE*
10. PHONE 2
12. CITY*
13. MAILING ADDRESS*
14. ZIP *
16. TOWN RESIDENT?*

    1. YES
    2. NO

    A TOWN RESIDENT IS DEFINED AS ONE WHO LIVES INSIDE THE CITY LIMITS OF BENSON OR WHO OWNS PROPERTY OR A BUSINESS INSIDE THE CITY LIMITS AND PAYS TAXES TO THE TOWN. A BENSON ADDRESS DOES NOT NECESSARILY CLASSIFY YOU AS A RESIDENT
17. PHYSICAL ADDRESS (IF DIFFERENT THAN ABOVE)
19. EMAIL ADDRESS*
    IF NO EMAIL ADDRESS IS GIVEN THEN YOU WILL NOT BE REGISTERED.
20. SHIRT SIZE*
    -- Select One --YXS (2-4)YS (6-8)YM (10-12)YL (14-16)ASAMALAXLAXXL
21. INTERESTED IN COACHING?

    1. YES
    2. NO
22. INTERESTED IN BEING A SPONSOR?

    1. YES
    2. NO
24. ATHLETIC WAIVER AND RELEASE OF LIABILITY (OVER 18 READ BEFORE SIGNING)

    1. I ACCEPT
    2. I DO NOT ACCEPT
    3. n/a

    In consideration of being allowed to participate in any way in The Town of Benson, Benson Parks and Recreation or other Town of Benson Depts. Youth and/or Adult athletic programs, related events, classes, activities and/or trips the undersigned acknowledges, appreciates, and agrees that: 1) The risk of injury could be significant and while particular rules, equipment, and personal discipline may reduce the risk, risk of serious injury does exist and: 2) I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, even if arising from the negligence of the releasees or others and assume full responsibility for my participation; and 3) I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and, 4) I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS BENSON PARKS AND RECREATION, their directors, officers, officials, agents, volunteers and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lesser of premises used to conduct the event (RELEASEES), with respect to any and all injury, disability, death, or loss or damage to person or property, whether arising from negligence of the RELEASEES or OTHERWISE, to the fullest extent permitted by law. HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field