Please Complete the CRPC Registration Form CRPC Registration Participant Information Name* E-mail* Phone* Address* Address City* State Zip Code* Please include me in text updates: Yes No Please include me in email updates: Yes No How did you hear about us* Catonsville Rec & Parks Email or Flyer Google/Internet Search I was at a Baltimore Zumba event Facebook YMCA Comments Emergency Medical Contact Information Emergency Contact* Phone* Relationship to Participant* Family Doctor* Doctor Phone Number* Family Medical Insurance* Does the registrant have any physical, emotional, psychological or social disorders, handicaps, diseases, disabilities or allergies? Yes No Is the registrant taking any medication that might affect his/her safety? Yes No If "Yes" to either of the above 2 questions, please indicate: Please check the box for agreement: If above question 1 or 2 was checked yes, I agree to provide a medical release prior to registrant engaging in this activity if requested by the Catonsville Recreation & Parks Council. Yes Does the registrant require any special accommodations due to a disability? Yes No If "Yes" to above question, please describe By checking the box I agree to each of the following:* Yes Liability Waiver: ACKNOWLEDGEMENT, WAIVER AND RELEASE OF LIABILITY: I hereby confirm participant is in good health and able to participate in the activity. Also, I have been advised to consult with a licensed physician prior to participation in the activity. I acknowledge the activity may involve both apparent and inherent risks and dangers of bodily injury or death and damage to property. I fully accept and acknowledge the activities may involve risks, and I hereby assume all dangers and risks associated with the participant in the activity and will be responsible for the same. I further understand that concussion information is available at www.cdc.gov/concussion. I acknowledge that Baltimore County, Maryland, the Recreation Council, and their respective employees, directors, officers, volunteers, members and any other participant, entity, party or person involved in any regard with the Activity or the Activity premises and their respective agents, personal representatives, heirs, employees, contractors, successors and assigns (each an activity representative and collectively the Permission to Administer First Aid: Permission is hereby granted for any coach, manager, leader, attendant, assistant coach or council official to authorize first-aid, as well as such medical treatment as may be deemed appropriate by a licensed physician for any illness or injury incurred or sustained by registrant while engaged in Catonsville Recreation & Parks Council activities. Register & Continue to select class package option Reset