Subject: Montgomery Township : Recreation : Registration Form
From: "Saved by Windows Internet Explorer 8"
Date: Tue, 15 Mar 2011 08:29:31 -0400

This form is not interactive. Please complete entire form, print & mail or deliver with payment. If you prefer on-line registration, go to www.twp.montgomery.nj.us/depts/recreation/registration.asp

Checks should be made payable to: Montgomery Recreation Department
Mail form & check to: Recreation Department, Otto Kaufman Community Center, 356 Skillman Rd., Skillman, NJ 08558.

If you have questions, call 609-466-3023. Classes may be canceled 1 week prior to start date based on registrations; please register early!

Registration Form All Programs Recreation Department

Last Name:

First:

Grade:

Age:

Street Address:

City:

State:

Zip:

Home #:

Work #:

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Course/Trip 1:

Course 1 Date/Time:

Cost 1:

Course/Trip 2:

Course 2 Date/Time:

Cost 2:

Course/Trip 3:

Course 3 Date/Time:

Cost 3:

Course/Trip 4:

Course 4 Date/Time:

Cost 4:

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Check Number:

Total Enclosed:

Parent/Guardian Name:
(Print or Type)

Date:

Emergency Contact Name:
(Print or Type)

Phone:

Email Address:
(Print or Type)

I understand that the programs in this brochure are sponsored by the Montgomery Township Recreation Department and hereby waive, release, absolve, indemnify, and agree to hold harmless, Montgomery Township, the class organizers, supervisors, and chaperones, for any claim arising out of an injury to myself/son/daughter. I understand I will not receive a refund for any class/program unless the class/program is cancelled by the Recreation Dept.

Adult Name (Print)_________________Signature: ___________________

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