The Fitz - Program Registration

Program Registration

Complete the form below to register for one of our programs.
Participant Information
Participant Name *

First Name Last Name
Gender *

Male Female
Date of Birth *

Month Day Year

Home Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parent/Guardian Information
Parent / Guardian Name *

First Name Last Name
E-mail *

Home Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Daytime Number *

Area Code Phone Number
Cell Number

Area Code Phone Number
Program

Beginner Skateboarding (9:30am - Noon) Intermediate Skateboarding (12:30pm - 3:00pm)

Liability Waiver

I, the undersigned parent/legal guardian of {participantName} do hereby consent to his/her voluntary participation in the Program and do forever RELEASE, acquit, discharge, and covenant to hold harmless The Fitzpatrick Collaborative or the coach/instructors 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 Fitzpatrick Collaborative 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 Town of Pepperell and The Fitzpatrick Collaborative or its successors, departments, officers, employees, servants, and agents any loss or damages or costs, including attorney's fees, The Fitzpatrick Collaborative 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 Name: {parent}
Parent / Guardian Signature *

Clear
Photography Release

I hereby give permission for my child to be photographed during The Fitz Big Backyard Summer Program. I understand the photos will be used to keep a journal of activities, to share during presentations, reports to our donors, and/or for promotional purposes including flyers, brochures, newspaper and on the internet. Your camper's identity will not be disclosed.
I agree to the terms of the photography release: *

Yes No

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
How did you hear about us?
Please add me to The Fitz mailing list.

Yes, please!
Signature Required

The Fitzpatrick Collaborative is not responsible for lost or damaged personal property. We encourage your child to leave electronics or other valuable items at home.
Parent / Guardian Signature *

Clear
Your Name *

First Name Last Name
Today's Date *

Month Day Year
Date Date Picker Icon
IMPORTANT! Once you click "Proceed to Payment," you will be taken to a page where you will select the program(s) you wish to register for and submit payment.
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