RETURN TO

1. Mayor Carpenter & the Brockton Public Schools Presents: RETURN TO Return Signed forms to: FREE! A Brockton’s Promise Initiative Mayor’s Office 45 School St July 7th, 2014 – August 28th, 2014 Activities: Check all that you plan to participate in.. Basketball Game Night Free Swim Outdoor Soccer Volleyball Hip-Hop Dancing Golf Tennis Boxing Flag Football Field Hockey Wrestling First Name (Please print in CAPITAL letters): Last Name: Age: Street Address: Zip Code: Email address: Phone: Sex (M/F): School: Grade in Fall: To participate, fill out the information above and sign below, If you are NOT a Brockton Public School student you WILL have to show proof of age and residency on the first night of activities • The Mayor’s Office and The Brockton Public Schools, with support from the Brockton Police Department, Brockton’s Promise, is sponsoring B.A.D. – Summer Evening Activities for Youth. The goal is to involve hundreds of young people, ages 13-20, in fun and active evening programs. • Registered sports participants will be organized into league play and take part in refereed games. For more info, please contact Catherine Walper at 508-897-6821. The undersigned participant and his/her parent or legal guardian (hereinafter “the undersigned”), if the participant is under the age of 18 years, do hereby execute this release waiver and indemnification for himself/herself and hereby agree and represent as follows: To release Brockton After Dark (B.A.D) and the City of Brockton and their officers, employees, and agents from any and all liability, loss damage, costs, claims or causes of action including but not limited to all bodily injuries including death and property damage arising from participation in any B.A.D sponsored activity. The undersigned further agree to indemnify and hold harmless B.A.D and the City of Brockton and their officers, employees, and agents from any and all liability, loss, damage, costs, claims or causes of action including attorney’s fees and witness costs, arising from participation in initiatives sponsored by B.A.D. The undersigned further gives to B.A.D and the City of Brockton, to its nominees, agents, assigns, and to the photographer, his/her free and unlimited consent and permission to use their photo, video, or film likeness, waiving all claims for any compensation by reason thereof or for damages for reasons thereof, to use, e-publish/broadcast, publish/rebroadcast or exhibit in the furtherance of its work, with or without identification of him/her by name. The Brockton Public School System neither endorses nor sponsors the organization or activity represented in this material. The distribution or display of same is provided as a community service. I request that my son/daughter be admitted into the Brockton After Dark program and I consent to allow him/her to participate in surveys required by state grants or B.A.D. to identify and / or assist in the further administration and enhancement of all programs provided for by B.A.D. Participant Signature: ________________________________ Date: ______ Parent/Guardian Signature: ___________________________ Date: ______ Emergency Contact Phone Number:________________________________ FREE FOOD SERVED AT MOST LOCATIONS!