16 North Street Ext
Rutland, VT 05701
Phone: 773-1822
Email: [email protected]
Website: www.rutlandrec.com
Office Hours: Mon – Fri
8:30AM – 5:00PM
INDOOR SPORTS @ Giorgetti Arena
Program Participation Waiver
(Please print clearly)
FIRST NAME:
LAST NAME:
STREET ADDRESS:
CELL #:
DOB:
CITY/TOWN & ZIP:
HOME #:
ARE YOU A RUTLAND CITY RESIDENT?
YES
WORK #:
/
NO
INFORMED CONSENT
I, the undersigned participant acknowledge, agree and understand that:
 Participation in this sport/activity is hazardous and may result in injury and that participation is potentially
dangerous to myself, my child and others.
 I also certify that myself and/or my child is physically capable of participating in this activity/program.
 Further, I agree that in consideration for permission to participate in the City of Rutland’s sponsored
programs or take part in activities at their facilities, I assume all risks of injury to myself and/or my child
incurred or suffered while on city premises while participating in programs.
 As a matter of caution, the Rutland Recreation and Parks Department strongly recommends that all
participants have accident and health insurance while taking part in programs or activities held on city
premises.
RELEASE: In consideration of your accepting this application in the Rutland Recreation Department’s
program or using their facilities, I hereby for myself, my heirs, executors and administrators, waive and
release any and all rights and claims for damages I may have against the City of Rutland, the Rutland
Recreation and Parks Department, their agents, representatives and assigns for any and all injuries suffered
by me in this program or activity.
Signature of Participant or parent/guardian if under age 18
Date
Circle the Program that applies:
Women’s 30+ Soccer
Adult Drop-in Soccer
Field Hockey
Youth Sport Drop-in
Group Rental
Youth Soccer:
U10 Boys
U12 Boys
MS Boys
HS JV Boys
HS Varsity Boys
U10 Girls
U12 Girls
MS Girls
HS JV Girls
HS Varsity Girls