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PlayNet Emergency Form

  1. PlayNet Emergency Form
  2. Program Information
  3. PlayNet Location:*
  4. Days*
  5. Children
  6. Program*
  7. Program
  8. Program
  9. Parent 1 Information
  10. Parent 2 Information
  11. Emergency Contacts
  12. Please list two emergency contact we can call if we are unable to reach you.
  13. Please list anyone NOT allowed to pick up your child.
  14. I give permission to Blaine Staff to perform minor first aid if required.*
  15. I give my child/ren permission to walk/bike home from Play-Net Blaine
    (Only applies to children in the regular PlayNet Program and NOT to the Juniors)
  16. Consent to Release of Information and Liability

    In consideration of your accepting this application, I authorize the City of Blaine to disclose to the City’s insurer, attorney, staff, coaches, participants and other personnel involved in this program the following information: name, address and telephone number. This information shall be used for the purpose of program administration. This consent to release information shall expire one year from the date of execution. I understand that the records are protected under the state and federal privacy regulations. I also understand that I may cancel this consent by a writing to that effect at any time prior to the information being released. I give my consent to use any photograph or video tape taken of myself for future promotional or marketing materials. In consideration of the City providing the registered activities, I agree to not hold the City liable for any claim resulting from participation in any such activity, including claims for injuries, death and resulting attorney fees. The completion of your registration signifies your acceptance of this consent.

  17. By checking this box, you agree to the waiver and liability clause above. *
  18. Leave This Blank:

  19. This field is not part of the form submission.