I hereby affirm that I am the parent or legal guardian of the above-named child and he/she has my permission to participate in the Jump Rope & Double Dutch program offered by the Town of Southington Recreation Department. I acknowledge the fact that a risk of injury
may exist due to the nature of the program. I agree to hold harmless the Town of
Southington, the Recreation Department, its instructors and all persons
connected with the program in the event of any injury incurred. I am also aware that there are no
medical personnel in attendance, and I authorize the program staff to act for me accordingly, using their best judgment, in the event of an emergency requiring medical attention.