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Dribbling to Better Health  
July 5-7
9am-3pm
Van Lieu Park - 90 Wilson Rd., Central Square
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Child's First Name  *
Child's Last Name *
Date of Birth  *
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DD
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Parent/Guardian Name *
Grade Entering in Fall '24
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Home Address (street, city, zip code)
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School District
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Parent/Guardian Email
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Parent Guardian Phone #
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Emergency Contact
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Emergency Contact Phone
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Allergies
Behavioral Issues (if any)
Any other important issue about your child:
Approved Pick Up People
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Student's T-Shirt Size (adult sizes)
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I, parent and/or legal guardian of the aforementioned minor, hereby authorize and give my consent that in my absence and ability to be reached or be pre-sent that the above named minor be admitted to any medical facility for diagnosis and treatment. In the event of an emergency I, the parent/legal guardian authorize the transportation of my child via ambulance and any and all medical treatment by ambulance staff and all emergency personnel. I hereby request and authorize any duly licensed medical staff to perform any and all medically necessary procedures on the above minor. I hereby authorize that in my absence or inability to be reached that The North Country Hub and or its representative be granted the authority to make any and all necessary medical decisions (using best judgment and upon advice of such medical or emergency personnel) for my minor child and hereby agree to hold the North Country Hub and/or its personal representatives, agents, assigns and/or directors harmless for the resulting consequences of such decisions. I recognize that as a result of medical treatment and care, costs may be incurred. I hereby recognize and acknowledge any medical payments and or costs for such medical treatment incurred, including but not limited to deductibles, medical services, prescriptions and co-payments, are my responsibility. I agree that under no circumstance will I seek any contribution from the North Country Hub, their insurer or hold them responsible for any costs as a result of medical expenses occurred for treatment.
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Release Agreement: Both Student and Parent/Legal Guardian need to read and check the boxes below. In consideration of participation at The North Country Hub (NC Hub), we, the undersigned parent/legal representative/guardian and student ("Releasor Student") (the parent/legal representative/guardian and Releasor Student shall be individually and collectively referred to herein as "Releasors"), hereby agree to indemnify and hold harmless and covenant not to sue NC Hub or its employees, agents, successors, assigns, volunteers, officers, and directors (individually and collectively referred to herein as "Releasees") and hereby waive, release and discharge Releasees from any and all claims for loss or damage, death, personal or bodily injury, or property damage which Releasors may have or which hereinafter may accrue to Releasors against Releasees and for any liability arising out of or connected in any way with Releasors' participation with NC Hub. Releasors hereby agree to indemnify and hold harmless and release from all liability, claims, demands, causes of action, charges, expenses, and attorney fees resulting from or relating to involvement in any activity at NC Hub or involvement with The NC Hub, whether caused by any negligent act or omission of the Releases or otherwise. It is further understood and agreed that this waiver and release has been entered into freely and will be binding upon Releasors and their heirs, successors, and assigns. Releasors expressly agree that the foregoing release and waiver, indemnity agreement and assumption of risk are intended to be as broad and inclusive as permitted by New York law and that, if any portion of this agreement is held invalid, void, or unenforceable for any reason, it is agreed that the balance or remainder shall, notwithstanding, continue to be in full legal force and effect. By signing this document, Releasors agree to allow images of Releasor Student (video, photo, other digital media) captured during programs/events to be utilized in printed materials, online or through the media. Releasors agree to waive any rights of compensation or ownership of these images. The NC Hub is not liable for images of your child (including Releasor Student) that are "tagged" or posted by other individuals on social media or other websites.  I, as Releasor, acknowledge I have read and agree to the program policies, permissions and Code of Conduct. By signing below I acknowledge I have read this document (Student Membership Application, including this Release Agreement), agree to same, and understand its contents and understand that the NC Hub is not a daycare and not responsible for keeping the child in their care.  The child is free to leave whenever they desire.
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