Summer Permission Form Summer 2019 Sign Up State regulations require we have parental contact information and one emergency contact person. Program enrolled in (required): Your Child's Name (required) Parent/Guardian Name (required): Child's Date of Birth (required): Phone (required): Email (required): Second phone contact in case of emergency: MEDICAL Any legal restrictions on the release of your child to a non-custodial parent (required)? YesNo Any medical restrictions we need to know about? YesNo Comments: Child is allergic to (please specify): EpiPen? YesNo Does your child have a disability and require accommodations to participate fully in program activities? Please contact the Disabilities Office at 978-630-9120 to discuss specific needs. PERMISSIONS I hereby allow MWCC to photograph the child listed above for use in any type of media MWCC deems appropriate. This can include, but is not limited to, newspaper stories, printed literature and online information. I hereby give MWCC, its legal representative and assigns, those for whom MWCC is acting, and those acting with its permissions, or its employees, the right and permission to copyright and/or use, reuse and/or publish, and republish, photographic pictures. I hereby allow MWCC to photograph the child listed above (required): YesNo PERMISSION AND ASSUMPTION OF RISK AND RELEASE I give my permission for the child listed above to participate in the selected program(s). I understand that in the unlikely event of an accident, every attempt will be made to contact the person(s) named on form. If unsuccessful, I give my permission to the staff to secure emergency medical services to aid my child, including (if necessary) hospitalization. Any expense arising from the injury or illness is the responsibility of the person signing below. In consideration of being permitted to participate in this program, I, the undersigned in full recognition and appreciation of the dangers and hazards inherent in such activities, which are described in this brochure, during my child’s enrollment and/or participation in MWCC activities during this program, do hereby agree to assume all risks and responsibilities surrounding my participation in this program, or activities undertaken as an adjunct thereto; and I assume all risks for injuries and illness; caused by or related to this program; and further I do for myself, my heirs and personal representative hereby defend hold, harmless, indemnify and release, and forever discharge MWCC and all its officers, agents, and employees from and against all claims, demands, and actions, or causes of actions, on account of damage to personal property, or personal injury or death which may result from my participation, and which results from the causes beyond the control of, and without the fault or negligence of MWCC, its officers, agents or employees, during the period of participation. I give my permission for the child listed above to participate in the selected program(s) (required): YesNo Parent/Guardian Initials (required): **REGISTRATION IS NOT COMPLETE AND YOUR CHILD(REN) CANNOT ATTEND UNTIL THE MEDICAL/PERMISSION FORM IS COMPLETED AND SUBMITTED.** Go to this link to download Medical Form Comments Please leave this field empty.