The Municipality of the County of Richmond - The Municipality of the County of Richmond

Please fill out a separate application form for each person. Fee is $10 per person and must be submitted to Sharla Mombourquette ASAP by mail to:
Municipality of the County of Richmond,
2357 Hwy 206 Box 120,
Arichat, NS B0E 1A0
Attention: Sharla Mombourquette

PERSONAL INFORMATION:

First Name

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Last Name

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Address

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City

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Postal Code

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Phone Number

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Cell Phone

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Gender

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Date of Birth (dd/mm/yyyy):(*)

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Email Address(*)

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Registration Fees:

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ACTIVITY AND SPORT (PARTICIPANTS ONLY) Please choose the Activity/Sport for which you are registering and please enter your partner's name below (only for WasherToss, Shuffleboard or Cribbage). If you do not have a partner one will be assigned to you.

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Partner for Washer Toss, Floor Curling, Floor Shuffleboard, Cribbage, 45's

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MEDICAL INFORMATION:

Health Card #:

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Expiry Date:

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Doctor's Name

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Dr’s Phone #

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Emergency Contact Person

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Relationship

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Emergency Contact Telephone Number(s):

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SENIOR GAMES WAIVER FORM The following agreement contains important provisions which limit the Liability of the organizers in the events of an injury and property damage and must be signed as a condition of participation in the 2017 Richmond County Seniors Games.

PHOTO PERMISSION: I give permission to the Municipality of the County of Richmond to use my name, image/photograph, and testimonial in publication and advertisement produced by, or for the Municipality of the County of Richmond. I understand that these publications will also be placed on web sites, news papers and poster managed by the Municipality of Richmond for public relations and advertising purposes. I also give permission for the Municipality of the County of Richmond to use the above information relating to me in any future publications and websites produced by or for the Municipality of Richmond for public relations and advertising purposes.

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YES I AUTHORIZENO I DO NOT AUTHORIZE Please choose one

I understand and fully accept that there are risks involved in sports and physical activities, and that accidents and injuries are possible in sporting events. I hereby release and hold harmless the Host Committee, the Municipality of the County of Richmond, and the Richmond County Seniors Council from all liability, and from all claims that I now or hereafter have for damages or injuries to my person or property, resulting from the negligence or other acts of any employees or volunteers in connection with my participation in the 2015 Richmond County Senior’s Games.

In case of a medical emergency, I hereby give permission to the organizing committee and volunteers to contact my emergency contact and make use of the information contained on this sheet for medical background information. I also understand that this information will be destroyed following the games.

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By Checking this Box you signify that you agree with the above statements. Invalid Input

The Registration Fee is $10. Please ensure that you have the name of the person(s) you are registering with the payment. Please send to: 2357 Hwy 206 Box 120 Arichat, NS B0E 1A0 Attention: Sharla Mombourquette

REGISTRATION PACKAGE - 6th ANNUAL RICHMOND COUNTY SENIORS GAMES – SEPTEMBER 9TH, 2017