Fall 2016 SWIM Registration Form

Fall 2016 PROGRAM Registration Form

Fall 2016 SWIM Registration Form

______________________________________________________________________________________________________________________________________________ FAMILY LAST NAME( Child name if different than parent) HOME PHONE WORK PHONE

______________________________________________________________________________________________________________________________________________ m Mr. m Mrs. m Ms. ADDRESS ZIP CODE

Swimming, Activity & Season Pass Registrations( Please list a 2nd choice for all swimming registrations.)

FIRST NAME AGE LEVEL DAY TIME FEE

______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________

Please sign waiver on back

______________________________________________________________________________________________________________________________________________

ATTENTION: Please list any medication( s) your child is currently taking or needs to be administered during our programs. Please list any health or behavior related conditions for which your child is being treated.

[ ] [ ] illcreek MILLCREEK TOWNSHIP- RECREATION & PARKS

______________________________________________________________________________________________________________________________________________ NAME

MEDICATIONS / CONDITION

Fall 2016 PROGRAM Registration Form

Please use this form for all other activities other than swimming.

______________________________________________________________________________________________________________________________________________

[ ]

FAMILY LAST NAME( Child name if different than parent) HOME PHONE WORK PHONE

______________________________________________________________________________________________________________________________________________ m Mr. m Mrs. m Ms. ADDRESS ZIP CODE

FIRST NAME AGE ACTIVITY DAY TIME FEE

Please sign waiver on back

______________________________________________________________________________________________________________________________________________ NAME

MEDICATIONS / CONDITION

Please make checks payable to: Millcreek Township Supervisors / Please sign waiver on back

Please mail registration and signed waiver to: Millcreek Recreation and Parks Department, Millcreek Municipal Building, 3608 West 26th St., Erie PA 16506

I( we) agree to the regulations for operation of the facilities; understand that the use of the pools and gyms are at the risk of the participant. All checks returned to us after deposit will be assessed a nonsufficient funds( NSF) fee.

Millcreek | Fall 2016 | icmags. com 19

IN Millcreek Fall 2016 | Page 21

Fall 2016 SWIM Registration Form

Fall 2016 PROGRAM Registration Form

Fall 2016 SWIM Registration Form

Please sign waiver on back

[ ] [ ] illcreek MILLCREEK TOWNSHIP- RECREATION & PARKS

Fall 2016 PROGRAM Registration Form

Please sign waiver on back