Volleyball Klinic

I hereby give my permission for my child to participate in 2023 Putnam Valley Volleyball Klinic and my child is in good health and does not have any health-related restraints that would not allow him/her to participate in such physical activity.  It is my understanding that my child will comply with the policies of the Putnam Valley Parks and Recreations Department and the program instructors.  My child and I are aware that participating in the Putnam Valley Volleyball Klinic is a potentially hazardous activity.  We assume all risks associated with participation in this sport or activity.  I acknowledge that even with the best coaching, supervision, and observance of rules, injuries are still a possibility.  I also understand that I have to either pick my child up or arrange to have transportation for my child each day.  Further, I authorize the Program Director(s) to provide emergency treatment of any injury or illness my child may experience if qualified personnel consider treatment necessary and perform the treatment.  This authorization is granted only if I cannot be reached, and a reasonable effort has been made to do so.


A credit or refund will be given for any program canceled by the Putnam Valley Parks & Recreation Department.  Once a participant has been enrolled in a particular program, refunds will not be considered, as these programs are dependent upon structure and pre-arrangement.  Therefore, anyone signing up pays a non-refundable fee.  Refunds would only be granted if the participant were to miss a prolonged period of time (more than half the program) due to injury/illness and is no longer able to participate for the remainder of the program.  When the participant becomes ill/injured, a doctor's note statement must be presented for verification.  All refunds given will be prorated from the date of notification to the Recreation Department.

Note: All fees are 100% refundable if requested ten days prior to program start dates.  Requested refund checks take at least two to four weeks to process.  The Town of Putnam Valley will charge a $20 service for returned checks.  Inquiries regarding refunds should be directed to: Putnam Valley Parks & Recreation Department.
Sign in to Google to save your progress. Learn more
Participant Name: *
Parent/Guardian Name: *
Email: *
Address: *
Home Phone #:
Cell Phone #: *
Date of Birth: *
Age: *
Child's Grade (2022-2023 School Year): *
Family Physician & Phone #: *
Medical Conditions: *
Any Known Allergies (Medical, Food or Other): *
Other Person to Contact in Case of Emergency: *
Relationship with Emergency Contact: *
Emergency Contact Home Phone #:
Emergency Contact Cell Phone #: *
I understand this informed Consent Form & Refund Policy, and agree to its conditions. (Type Parent/Guardian Name & Date) *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy