Brockton After Dark Registration Form
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Register for a program of your choice for Brockton After Dark. Return to Patricia Godio at the Mayor\'s Office. 45 School Street, Brockton, MA 02301
Brockton After Dark Registration Form
- 1. Free! Every Weeknight from 6:00 to 10:00 PM June 28 th to August 20 th 2010 BROCKTON AFTER DARK RETURN TO FREE! Return Signed forms to: The undersigned participant and his/her parent or legal guardian (hereinafter the undersigned), if the participant is under the age of 18 years, do hereby execute this release waiver and indemnification for himself/herself and hereby agree and represent as follows: To release Brockton After Dark (B.A.D) and the City of Brockton and their officers, employees, and agents from any and all liability, loss damage, costs, claims or causes of action including but not limited to all bodily injuries including death and property damage arising from participation in any B.A.D sponsored activity. The undersigned further agree to indemnify and hold harmless B.A.D and the City of Brockton and their officers, employees, and agents from any and all liability, loss, damage, costs, claims or causes of action including attorneys fees and witness costs, arising from participation in initiatives sponsored by B.A.D. The undersigned further gives to B.A.D and the City of Brockton, to its nominees, agents, assigns, and to the photographer, his/her free and unlimited consent and permission to use their photo, video, or film likeness, waiving all claims for any compensation by reason thereof or for damages for reasons thereof, to use,e-publish/broadcast, publish/rebroadcast or exhibit in the furtherance of its work, with or without identification of him/her by name. The Brockton Public School System neither endorses nor sponsors the organization or activity represented in this material. The distribution or display of same is provided as a community service. I request that my son/daughter be admitted into the Brockton After Dark program and I consent to allow him/her to participate in surveys required by state grants or B.A.D. to identify and / or assist in the further administration and enhancement of all programs provided for by B.A.D. Participant Signature: ________________________________ Date: ______ Parent/Guardian Signature: ___________________________ Date: ______ Emergency Contact Phone Number:________________________________ First Name (Please print in CAPITAL letters): Last Name: Age: Street Address: Zip Code: Email address: School: Phone: Grade in Fall: Activities: Check all that you plan to participate in . See detailed schedule on reverse side. Basketball Outdoor Soccer Volleyball Tennis Free Swim Hip-Hop Dancing For more info, please contact Patricia Godio at the Mayors Office:(508)897-6821 or pgodio@ci.brockton.ma.us The Mayors Office, with support from the Brockton Police Department, Coca-Cola, local churches, youth serving agencies and corporate support, is sponsoring B.A.D - Summer Evening Activities for Youth. The goal is to involve hundreds of young people, ages 13 20 in fun and active evening programs. Registered sports participants will be organized into league play, & take part in refereed games. FREE FOOD at most locations -BHS Main Office -Jr. High Main Offices -Boys and Girls Club -YMCA -Mayors Office To participate, fill out information above and sign below. A Brocktons Promise Initiative Sex (M/F): FREE FOOD SERVED AT MOST LOCATIONS! Ballroom Dancing Boxing Acting Class Mayor Balzotti & the City of Brockton present Open- Mic Ladies Night Out Arts and Crafts Jewelry Making