Summer 2019 SWIM Registration Form
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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.
m Ms.
ADDRESS
list a 2nd choice for all swimming registrations.
[ Please
You will only be notified if your 2nd choice is selected. ]
Swimming, Activity & Season Pass Registrations
FIRST NAME
AGE
POOL
ZIP CODE
SESSION
LEVEL
TIME
FEE
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n
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r o
e
v
i
wa
______________________________________________________________________________________________________________________________________________
sign
e
s
ATTENTION: Please list any medication(s) your e
l child a is currently taking or needs to be administered during our programs. Please list any health or
behavior related conditions for which your P
child is being treated.
back
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NAME MEDICATIONS/CONDITION
Summer 2019 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
______________________________________________________________________________________________________________________________________________
m Mr.
m Mrs.
FIRST NAME
m Ms.
ADDRESS
AGE
ACTIVITY
ZIP CODE
LOCATION DAY TIME FEE
______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
on
______________________________________________________________________________________________________________________________________________
er
v
i
a
w
______________________________________________________________________________________________________________________________________________
sign
e
s
ATTENTION: Please list any medication(s) your e
l child a is currently taking or needs to be administered during our programs. Please list any health or
behavior related conditions for which your P
child is being treated.
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
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.
**All checks returned to us after deposit will be assessed a non-sufficient funds (NSF) fee.
MILLCREEK
❘
SUMMER 2019
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