Johnson Park Registration
Rockdale Rapids

Name:        Male:    Female:

Address:

City, State, Zip:        County:

Phone:

School:    Age:    Date of Birth:

Parents Names:    Home phone:    Cell Phone:

Parent Email:

Doctors Name/Phone    Emergency Contact (name and number):

Allergies/Medications:

If Any medical conditions exist you must bring a letter of clearance from your Dr. in order for your child to participate. Please make sure you tell us if there is anything medically we should know.

There is no medical conditions that will prevent or harm my child while participating in the Rockdale Swim Program. Please check here   

 Waiver                I the above named, or legal guardian of the above named boy or girl, herby agree to save and hold harmless Rockdale County, members of the board of commissioners, and all employees of Rockdale County, including all individuals who are affiliated with the programs administered by the parks and Recreation department of Rockdale County, as coaches or otherwise, as the result of personal or bodily injury or damages to me, my child or my ward caused by negligence or other acts of any of the above named individuals or entities while participating in any activities administered by the parks and Recreation Department or Rockdale County, while coming to and going to those activities, and further release and agree to full indemnify them from liability in the event that damages are awarded against any of the above arising out of injuries to me or my child or my ward. I assume all risks and hazards incidental to the conduct of the activities and transportation to and from those activities.

                I understand that health or accidental insurance, which would cover my child’s medical, hospital, or related expenses in the event of injury in this activity, is my responsibility. I acknowledge that the Parks and Recreation Department of Rockdale County strongly recommends that if I do not have sufficient insurance to cover such incidents that I take the necessary action to obtain it.

Signature__________________________________ Date______________________

** Administrative Use Only     Fee:______   Check:______   Receipt#_____   Date:________