2015/2016 Randolph Ice Rink Season Pass Registration

Pass Type

Check one:
(Rates are divided into Resident and Non-Resident Rates)

Individual

Randolph Resident: $50

Non-Randolph Resident: $60

Family

Randolph Resident: $75

Non-Randolph Resident: $100

10 Punch Card

Randolph Resident:
$35 adult/$20 youth

Non- Randolph Resident:

$45 adult/ $30 youth

*A family is up to two adults ages 19 and older, with up to four children living together at the same
address. There is a $10 fee for each additional child.
Information:
Primary Pass Holder: _____________________________________________________D.O.B. _________________________
Address: _________________________________________________________________Home phone:__________________
City____________________________________________State_________________________Zip______________________
Medical Concerns/ Medications:____________________________________________________________________________
Emergency Contacts (Other than names listed on pass)
1:____________________________________________________Phone:_____________________
2:____________________________________________________Phone:_____________________
Please list additional family members below:
Name: _________________________________________________ D.O.B: _____________Relationship: _______________
Medical Concerns/ Medications:___________________________________________________________________________
Name: _________________________________________________ D.O.B: _____________Relationship: _______________
Medical Concerns/ Medications:___________________________________________________________________________
Name: _________________________________________________ D.O.B: _____________Relationship: _______________
Medical Concerns/ Medications:___________________________________________________________________________
Name: _________________________________________________ D.O.B: _____________Relationship: _______________
Medical Concerns/ Medications:___________________________________________________________________________
Name: _________________________________________________ D.O.B: _____________Relationship: _______________
Medical Concerns/ Medications:___________________________________________________________________________

Additional Family members: ($10 per member)

Name: _________________________________________________ D.O.B: _____________Relationship: _______________
Medical Concerns/ Medications:___________________________________________________________________________
Name: _________________________________________________ D.O.B: _____________Relationship: _______________
Medical Concerns/ Medications:___________________________________________________________________________

COMPLETE ON REVERSE SIDE

Note:

Please make checks payable to the Town of Randolph Recreation.

All individuals listed on this pass must abide by the Randolph Ice Rink rules and follow all directions given by the staff.
Failure to adhere to the rules may result in suspension of rink pass for the rest of the season without reimbursement of
fees paid.

All unsupervised youth between the ages of 10-17 must have a signed minors form and sign in and out of the rink.

The Season Pass is only good for open skate and does not include any lessons, birthday parties, or rentals.

There will be no refund for the purchase of this pass once payment is received

Punch Passes are issued to one person per pass. They are non- transferrable and non-refundable.

Please review the following and sign and date below to indicate your permission:
Release of Liability: I authorize the staff and volunteers of the Randolph Recreation Department to provide basic first aid or to call
additional medical care in the event of an emergency, for all individuals listed. I understand the inherent risk in participating in this
program and hereby give my consent, for all named individuals, to participate in programs offered by the Town of Randolph
Recreation Department. I further agree to release the Town of Randolph and their staff and volunteers from any liability connected
with listed individuals participation in this program.
Consent: I hereby consent to and authorize the Town of Randolph Recreation Department the rights to publish, reproduce and
use for advertising or any other purpose any photograph, video image, audio recording and other likeness of individuals listed on this
registration.

Parent/Guardian Signature: _____________________________________________________ Date: ___________________

FOR OFFICE USE ONLY:

Date Received: ___/___/___ Cash: $_____ Check: #_____ Amount: ______ Staff initials:________

Randolph Recreation Department, 7 Summer Street, PO Drawer B, Randolph, VT 05060

Phone (802) 728-5433 x 18 Fax (802) 728-5818 Email: rec@randolphvt.org