Copy of New Registration Form by tamir13

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									                              Program Registration Form
                                                      Mail or Fax Program Registrations to:
                                    Newington Parks & Recreation, 131 Cedar Street, Newington, CT 06111
                                                Phone: (860)665-8666 Fax: (860)665-8739



Adult Name:_____________________________Address:__________________________________

City/State:________________________Zip Code:_______________Email:___________________

Home Phone:________________ Cell Phone:________________ Work Phone:________________

Has this information changed since your last registration form:                                             YES          NO

In the event of an emergency, please list someone who we can contact:
Name:______________________________Relationship:______________________Phone:____________________

* A copy of the child’s Birth Certificate is needed for all Preschool Age Programs.
Please list the name of participant and any medical concerns he or she may have: (i.e. allergies, asthma, medications, or physical difficulties

_________________________________________________________________________________________________________________

Assumption of Liability: Participation in the activity may involve risk or injury. As a parent, guardian, or participant, I am aware of these hazards and my ability to
participate. I hereby agree to release, discharge and hold harmless the Town of Newington, its employees, contracted instructors, and volunteers from the liabilities
which may occur while participation in the activity. I understand that participation in any recreational or sport activity involves risk. I further understand that the
Town of Newington does not provide accident/medical insurance for the program participants. In addition, I give permission for the child(ren) to be treated by quali-
fied medical personnel in the event that the above named parent/guardian/emergency contact cannot be reached at the phone numbers provided. The Parks and Rec-
reation Department reserves the right to photograph program participants for publicity purposes. Please be aware that these photos are for Parks and Recreation use
only and may be used in future catalogs, website, brochures, pamphlets, and/or flyers.

SIGNATURE:_____________________________________________________________________________DATE:_________________________


                                                                      Program ID                Program ID
Name of Participant                 M/F       Date of Birth           1st choice                2nd choice           Program Name                       Fee




                                                                                                                                   TOTAL:_________

 Please Circle Payment:                Cash         Check         Visa         Mastercard            Discover                   TOTAL: $_________

 Credit Card#                                                                                                         Expiration Date:___________

 Signature for Credit Card Use:_________________________________________ Date:____________________

								
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