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2. Program Participation Form
4. Participant Name*
6. Gender*

   1. Male
   2. Female
7. Date of Birth*
   Date of Birth
9. Parent/Guardian’s Name

   If applicable.

11. Address*
13. City*
14. State*
15. Zip Code*
17. Phone Number*
18. Email Address*
22. Emergency Contact Information
24. Emergency Contact Name*
26. Relationship*
27. Phone Number:*
29. Please list any medical conditions/allergies/etc.*
31. If you have a disability and require an accommodation in order to participate, please explain: *
35. Town of Farmville Resident*

    1. Yes
    2. No
37. Please select the classes and/or programs that you will be participating in:*

    1. Fishing With Friends: FREE (Ages 7 to 13; Wilck's Lake Island)
    2. Karate: $5 per session (124 South Street, 2nd floor)
    3. Pickleball: $2 per session (1328 Zion Hill Rd)
    4. Indoor Walking: FREE (1328 Zion Hill Rd)
39. Payments

    Payment must be made to the Town of Farmville Treasurer's Office (Monday to Friday, 8am to 5pm). For in person payments (cash, check, or card), visit the Treasurer's Office at 116 North Main Street, Farmville, VA 23901.

    Payments may also be made over the phone by calling the Treasurer's Office: (434) 392-3333.

    Mailed payments can be addressed to: Town of Farmville Recreation Dept. (P.O. Drawer 368, 116 North Main Street, Farmville, VA 23901)

43. Waiver Acknowledgement- Participant or Parent/Guardian Full Name

    We consent to participate in the Farmville Recreation Department Programs. In participating in Recreation Programs, sponsored by The Town of Farmville, I hereby acknowledge that I/We understand that there are risks of accidents resulting in bodily harm arising out of those activities. I/We understand that Recreation activities are planned with the safety of the participants in mind. In case of emergency, accident, or illness, if I/We are not present I/We hereby give our permission for the representative of the Recreation Department to obtain any required medical attention that may be needed. I/We will notify the representative of any physical limitations (allergies, hearing, sight, etc) or other additional information they need to know about the participant. I/We further acknowledge that the participant has the physical capacity reasonably necessary to engage in the Recreation activity for which they have enrolled. I/We agree to be the party responsible for all medical expenses which are incurred on my behalf. It is understood and agreed that the Town, Mayor, Town Council, Boards, employees, volunteers, and agents shall be held harmless against all claims, damages, losses, or expenses including attorney’s fees arising out of or resulting from participation in recreation programs. I/We agree any pictures taken may be used for future promotions for the Town of Farmville.

45. Please type your full name to acknowledge you have read the above waiver and understand the contents.*
47. Date of Waiver Acknowledgement*
    Date of Waiver Acknowledgement
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49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field