THOMASTON-UPSON COUNTY RECREATION & PARKS DEPARTMENT

YOUTH PARTICIPANT FORM

Skate Park

Name _______________________________ Mailing Address _____________________________

City ______________________________ Reside Inside ____ Outside ____ City Limits

Telephone _______________________ Date of Birth __________________ Age ____________

Male _____ Female _____ Grade _______ School ______________________________________

Parent's Name ___________________________ Email Address ___________________________

Business Phone Father __________________________ Mother _________________________

Home Phone Father __________________________ Mother _____________________________

In the case of emergency:

Name of Adult contact person ________________________________________________________

Cell phone # of Adult contact ____________________________________________________

Doctor ______________________________________ Phone _____________________________

Child's Physical Condition _____________________________________________________

___________________________________________________________________________

(List any physical or mental handicaps or diseases such as epilepsy, heart murmur, rheumatic fever, etc. which your child may have or any other special medical information which may affect your child's participation).

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PARENT'S SIGNATURE __________________________________________ DATE _____________________