IN Millcreek Winter 2019 | Page 27

Winter 2020 SWIM Registration Form [ [ ] ] ______________________________________________________________________________________________________________________________________________ FAMILY LAST NAME (Child name if different than parent) ­ HOME PHONE WORK PHONE ______________________________________________________________________________________________________________________________________________ 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 ______________________________________________________________________________________________________________________________________________ ck a b on ______________________________________________________________________________________________________________________________________________ r e v i a n w ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ se a e l P sig ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ 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 Winter 2020 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. FIRST NAME m Ms. ADDRESS AGE ACTIVITY ZIP CODE LOCATION DAY TIME FEE ______________________________________________________________________________________________________________________________________________ ck a b on ______________________________________________________________________________________________________________________________________________ r ive a w n ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ g si e s lea ______________________________________________________________________________________________________________________________________________ P ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ 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 25