Name:_______________________________Telephone:________________________

Address:_____________________________________________________________

Medical Insurance Comapny:_____________________________________________

In case of Emergency, call (if different than home):______________________________

Recreation Activity: April 21, 2012 Bus Trip to the Cloisters and the Metropolitan Museum of Art

I, the undersigned, intending to be legally bound for myself, my heirs, executors, administrators, and assigns, hereby waive and release any and all rights and claims for damages I may now or hereafter have against West Goshen Township and its respective employees for any and all damages or injuries which may be sustained by me or my family arising out of participation in the above activity.

______________________________          _____________________________
           Signature                                       Date

Each person over 18 years of age participating in the above mentioned event must complete and return this form to the Park and Recreation Office. Parents or guardians of children under 18 must complete the Parental Permission Form.