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HOME PHONE
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ADDRESS
ZIP CODE
Swimming, Activity & Season Pass Registrations (Please list a 2nd choice for all swimming registrations.)
AGE
POOL
SESSION/LEVEL DAY
TIME
ownship - R
FIRST NAME
illcreek T
FAMILY LAST NAME (Child name if different than parent)
Millcreek
Summer 2014 SWIM Registration Form
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NAME MEDICATIONS/CONDITION(S)
Summer 2014 PROGRAM Registration Form
Please use this form for all other activities other than swimming.
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FAMILY LAST NAME (Child name if different than parent)
HOME PHONE
WORK PHONE
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m Mr.
m Mrs.
FIRST NAME
m Ms.
ADDRESS
AGE
ACTIVITY/LEVEL
SESSION/WEEK#
DAY
ZIP CODE
TIME LOCATION
FEE
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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.
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NAME MEDICATIONS/CONDITION
Please make checks payable to: Millcreek Township Supervisors / Please sign waiver on back
In applying to the Pool Season Passes listed on the following pages, 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; and further acknowledge that passes may not be loaned and are limited to my (our) immediate
family; the permit and those privileges associated with it are not transferable and will be lifted if presented at the entrance by anyone else.
Millcreek | Summer 2014 | icmags.com 15
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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.
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