Winter 2020 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
Swimming, Activity & Season Pass Registrations
FIRST NAME
AGE
POOL
WEEK DAY
ZIP CODE
list a 2nd choice for all swimming registrations.
[ Please
You will only be notified if your 2nd choice is selected. ]
LEVEL
TIME
FEE
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sig
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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
Winter 2020 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
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ive
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lea
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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.
______________________________________________________________________________________________________________________________________________
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
❘
WINTER 2019
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