WEST GOSHEN TOWNSHIP
PARTICIPANT RECREATION FORM

Name:_______________________________Telephone:________________________

Address:_____________________________________________________________

Medical Insurance Comapny:______________________________________________

In case of Emergency, call (if different than home):______________________________

Cell phone number for emergencies during event:_______________________________

Recreation Activity and Date: Bus trip to Statue of Liberty and Ellis Island, June 25, 2011

I, the undersigned, intending to be legally bound for myself, my heirs, executors, administrators, and assigns, hereby waive and release any and all rights and claims for damages I may now or hereafter have against West Goshen Township and its respective employees for any and all damages or injuries which may be sustained by me or my family arising out of participation in the above activity.

______________________________          _____________________________
           Signature                                       Date

Each person over 18 years of age participating in the above mentioned event must complete and return this form to the Park and Recreation Office. Parents or guardians of children under 18 must complete the Parental Permission Form.