PARTICIPENT INFORMATION

FIRST NAME:  __________________ LAST NAME: ___________________________    MI:   ____ 

STREET ADDRESS:  ________________________________________________  APT:  _________

CITY:  ______________________ STATE:  ____ ZIP:  ________ CHILD’S D.O.B.  _____________

   HOME PHONE: _______________ Age:  _______                                                                                  

Parent or Guardian: _________________________             .

SCHOOL: _____________ Scout Troop: ________  Scout Master:  ____________________________

        1.   Andrew E. Zimmer Fish and Game Protective Association       Participant’s Signature is required in this box.

        2.  Zimmer Club Youth Conservation Program of Staten Island

        3.   Colonial Rifle and Pistol Club

        4.   Staten Island Sportsman’s Club and their affiliated members

        5.   NYC Department of Youth and Community Development

        6.   NYC & NYS Department of Parks & Recreation              

            I hereby give permission to ______________________________________________________

                                                                        (Print name of student/participant )

to attend events and/or classes at the above mentioned clubs and will not hold the above organizations, their members, or their instructors responsible for injuries occurring during class events on or off the site.  I do understand that some of the classes are dangerous and could cause a serious injury to my child.  

            Special Medical/Physical Alerts(ie: asthma, Etc)_____________________________________

             Doctor_______________________________________ Telephone_______________________

             Signed:________________________________________________  Date_________________

                                          (Student/Participant if 18 or over)

            Signed:________________________________________________  Date_________________

                                          (parent or guardian)                                                                                                        

   Special Alerts (ie Asthma or other Medical or Physical Condition) That may affect my child’s or ward’s participation in a Youth event sponsored by  this  Organization: _______________________________________________________________________________________________

Doctor:  _______________________________________________  Telephone:  _________________

 I have read both sides of this form and do acknowledge its contents.  By signing the reverse side I do hereby give permission for my child or ward to participate in what is generally considered a harmless or a low risk of injury event but may be perceived by others as hazardous.  I hold harmless the aforementioned Organization indicated on the reverse side of this form during any of its:  Youth Activities, Tournaments, Programs, and Games.  I also will allow an electronic attendance sheet or Club Identification card to be generated with my child or ward’s signature and printed name on it when he participates.  I also allow an electronic authorization signature sheet with my name to be used in conjunction with his activities when required.  I also will allow an electronic picture to be affixed to my child or ward’s demographic record or Club Identification card with his or her signature may be affixed.  I also hold harmless and allow the following organization:  Andrew E. Zimmer Fish & Game Protective Association, Colonial Rifle & Pistol Club, NRA, Staten Island Sportsman Club, NYC Department of Youth & Community Development, NYC Department of Parks & Recreation, and any other organization’s location being used to stage an event where my child or ward identified on the reverse side of this form may participate in the activities of Staten Island Youth Conservation Program of Staten Island.