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Town of Westport
Parks & Recreation
Road Runners Summer Series - 2008
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Please print and complete this application in full and
bring to the first session of program in which you participate.
Name: ________________________________________
Address ______________________________________
Town ______________________________________Zip____________
Age: ________ Sex: _______
Date of Birth (mm/dd/yy) __________________________
Phone: (_____) _____ - ______________
Waiver (must be signed)
I am aware of the nature of this activity and
hereby assume responsibility for my child or myself to
participate. I will not hold the Town of Westport, the Department
of Parks and Recreation and/or its employees, agents or
volunteers responsible in case of accident or injury as a result
of this participation. Unless indicated below, the Westport Parks
and Recreation Department may use photographs including my child
or myself for promotional purposes.
NO______________
Signature- (Parent/Guardian's signature if
under 18)____________________________________
Date:______________
| For the Series: |
$30 for Westport residents |
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$50 for Non-residents |
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| Not for the Series: |
$5 weekly fee for residents |
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$8 weekly for Non-residents |
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TOTAL $_____ |