**CONFIRMATIONS WILL ONLY BE SENT VIA EMAIL Sixth Annual Mother / Daughter Dinner Dance CIRCLE DATE: March 28th – 13132301 April 5th - 13132302 April 11th - 13132303
Mother's Name Daughter's Name Daughter's Name Daughter's Name Address
D/O/B D/O/B D/O/B
Grade Grade Grade Phone
School School School
If possible, we would like to sit with: (tables of ten preferred) - In order to insure your entire table will be registered for the same date, send in all registrations together.
Payment Enclosed $
By registering for this program I hereby give permission for the Middletown Township Parks & Recreation and the Township of Middletown to use, in its future brochures and any other program publicity and/or broadcasts of any kind, any program pictures, audio or video in which I/we appear.
Parent or Guardian Signature X
Mail to: Middletown Parks & Recreation 900 Leonardville Rd. Leonardo, NJ 07737 For more information contact: (732) 615-2260 x. 2235