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Meadowbrook Park Clubhouse Youth Programs

  1. Meadowbrook Park Clubhouse Youth Programs

  2. This form will be shared with JCPRD staff for administration purposes.

  3. Is child taking presciption drugs? *

  4. Registering another child?*

  5. ADD ANOTHER CHILD

  6. Is child taking prescription drugs?

  7. Register Another Child?*

  8. ADD ANOTHER CHILD

  9. Is child taking prescription drugs?

  10. What is the best way to reach you? *

  11. What is the best way to reach you?

  12. Child Release Information:

    My child may be released to the following individuals without advance written or verbal permission. All individuals picking up child(ren) must have photo ID to pick up child.

  13. Electronic Signature Agreement*

    By checking the "I agree" box below, “The undersigned states that he/she understands that the Johnson County Park and Recreation District is not and shall not be responsible for or liable for any illness, or injury to person or damage to property resulting from the program in which the undersigned is enrolling or being enrolled or from his/her participating in said program, and the participant and the undersigned, if the participant is a minor or under other legal disability, hereby forever releases and holds harmless the said Johnson County Park and Recreation District, its employees, agents and representatives from any and all claims of any kind that the participant, or the undersigned, or their respective heirs, executors, administrators, or assigns may have or claim to have resulting from participation in said program. NOTICE: By enrolling in this program you hereby acknowledge the Johnson County Park and Recreation District can and may photograph and/or video tape program participants and then use such images, without payment or any other consideration, for purposes of publicizing District parks, facilities, programs or services, or for any other lawful purposes. I have read and understand the waiver statement.

  14. Leave This Blank:

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