VER Recreation 2026 Participant Registration Form

January 2026 - December 2026   One-Year Registration Form

Child's NAME: CELL PHONE NUMBER:

ADDRESS: TOWN: ZIP:

DATE OF BIRTH GRADE:

EMAIL:

EMERGENCY CONTACT NAME:

EMERGENCY CONTACT PHONE #:

FOR PARENTS/LEGAL GUARDIANS OF PARTICIPANTS UNDER THE AGE OF 18:

I, , the parent or legal guardian of (participant), hereby covenant and agree to indemnify, release and hold harmless the: Incorporated Village of East Rockaway, all of the elected and appointed officers, directors, employees, volunteers, and/or agents, from and against any and all liability, loss, damages, claims, or actions (including costs and attorney fees) for any harm, bodily injury including economic, physical, or mental, including death, or property damage caused by the negligence of the Village or otherwise incurred by above named participant to the fullest extent permissible by law, arising out of his or her participation in any. I understand his/her participation in all programs registered for during the year 2023 involves rigorous physical activity and risks of physical injury and I assume the risks. I hereby give consent for transportation and treatment of above-named participant in the event of illness or injury. I hereby accept responsibility for the payment of any transportation or treatment costs. I further certify that the above-named participant is in good physical condition and has no medical or physical conditions that would restrict his/her participation in this program/event. I understand my signing for the above-named participant is valid for all programs within the year beginning January 1, 2025 and ending December 31, 2025.

Your participation in a Village of East Rockaway Recreation program or event provides consent to the Department to use photos and stories providing information about the Department and its programs and events to the public.

Signature of Parent/Guardian: Date:

Refund Policy:

• A full or partial refund will be issued for any program canceled by the East Rockaway Recreation Department
• Refunds due to illness or accident will be reviewed and must be submitted in writing and accompanied by a DOCTOR'S NOTE
• Returned checks will incur a $35.00 service charge. Cash or a money order will be required immediately for redeposit.
• CREDITS ONLY if you cancel within 48 hours of the program's start.
• Online payment fees are NOT refundable at any time.

Payment options:

ONLINE PAYMENTS: Visit the Village of East Rockaway homepage to the Make a Payment tab. Select East Rockaway Recreation and the program you are paying for. Please note, a 3% processing fee will be applied and is not refundable.

LOCKBOX PAYMENTS: Payments by CHECK ONLY may be placed in an envelope, specifying the program the payment reflects. Our lockbox is located at the entrance doors of the recreation building at 17 John Street.

Mail-IN PAYMENTS: Payments by CHECKS ONLY may be mailed to 376 Atlantic Avenue, East Rockaway, NY 11518

• Completed registration forms must be emailed to NLanderer@villageofeastrockaway.org or included with your payment in our lockbox of mail.
• All programs have a minimum participation. If the minimum participation is not met, the programs will be cancelled. An email notifying you of the cancellation will be sent before the start date. All payments will be refunded except for the online processing fees.