Groton-Dunstable Community Education
DATES: 8 Sundays, Sept. 11 - Nov 6 (no program Oct 9)
TIME: 11:00 am – 12:30 pm
COST: $45 registration received by September 2
$55 registration received September 3-7
$75 registration received after September 7
LOCATION: Middle School South Field for MS Grades
Florence Roche Field for Grades 3 & 4
A FUN & SAFE SPORT FOR GRADES 3–8
Enjoy Team Play, Learn Individual Skills – passing, kicking, blocking, & punting.
PLENTY OF ACTION EACH WEEK WITH A SUPERVISED GAME!
INCLUDES A SHIRT!
Volunteer Coaches and Referees are needed!
PLEASE FILL OUT THE REGISTRATION & CONSENT FORM and mail with
CHECK payable TO GDRSD TO: GDRSD Comm Ed, PO Box 426, Groton, MA 01450
You may drop off at the Peter Twomey Youth Center any time (there is a drop off box located by main
entrance if the building is closed).
It is the policy of the Groton-Dunstable Regional School District not to discriminate on the basis of race, color, sex, gender identity, religion, national
origin, sexual orientation, disability or homelessness in its educational programs, activities, or employment policies as required by Title IX of the 1972
Education Amendments, Chapter 622 of the Acts of 1971, and Section 504 of the Rehabilitation Act. Also, students will not be excluded for reasons of
marriage or pregnancy. Requests for information about these laws and/or grievance procedures should be directed to the Office of the Superintendent,
Groton-Dunstable Regional School District, (978) 448-5505.
(PLEASE KEEP TOP PORTION for Dates, Time, & Location)
DO NOT TURN form & check in to the School, Teacher,
or Extended Day Staff – any forms turned in will be returned to the student.
Forms must be mailed or dropped off at the Twomey Center.
CUT HERE
– PLEASE KEEP TOP PORTION of the OTHER SIDE
For INFORMATION on DATES & TIMES
You will not get a confirmation email
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GROTON-DUNSTABLE COMMUNITY EDUCATION
2016 FLAG FOOTBALL REGISTRATION
Student’s Name______________________________________________________________________________________
(ONE CHILD PER FORM)
Parents’/Guardians’ Name______________________________________________________________________________
Home Phone#_______________________________ Cell #__________________________________________________
Parent E-Mail –required (please print clearly) _____________________________________________________________
GRADE (not age) AS OF 9/2016____ Student’s D.O.B.______________Height_______Weight_______Shirt Size_____
Medical Information (allergies, etc) ______________________________________________________________________
Emergency Contact Name (if parent cannot be reached) ___________________________________________________
Emergency Contact Phone #(s) ________________________________________________________________________
Permission to Publish Photos: __Yes __ No
VOLUNTEER to ___ Coach ____Referee
I/we the undersigned parent/legal guardian of _______________________________do hereby consent to his/her voluntary participation in the Program
and do forever RELEASE, acquit, discharge, and covenant to hold harmless the Groton-Dunstable Regional School District and its successors and agents
of and from any and all actions, causes of action, claims, demands, damages, costs, loss of services, expenses, and compensation on account of, or in
any way growing out of, directly or indirectly, all known and unknown personal injuries or property damages which I/we may now or hereafter have as
the parent(s) or guardian(s) of said minor and also all claims or right of action for damages which said minor has or hereafter may acquire, either before
or after he/she has reached his/her majority resulting or to result from his/her participation in this Program; FURTHERMORE, I/we hereby agree to
protect the GDRSD and its successors, departments, officers, employees, servants, and agents against any claims for damage, compensation, or
otherwise on the part of the said minor growing out of or resulting from injury to said minor in connection with his/her participation in this voluntary
Program and to INDEMNIFY, reimburse, or make good to the GDRSD or its successors, departments, officers, employees, servants, and agents any loss
or damages or costs, including attorney's fees, the District or its representative may have to pay if any litigation arises from said minor's intentional,
grossly negligent, or reckless acts or missions while participating in said Program.
__________________________________________________________
Parent/Guardian Signature
____________________
Date