Upper Merion Park & Recreation Registration Form    [Print Form]    [Close Form]
Program/Activity Name:
Selection:	0
Registrant's Information:
Last Name/First Name:
Age/Birth Date:	Male    Female    (circle one)
Home Phone/Email:
Address 1/Address 2:
City/State/Zip:
Special Needs/Medication:
Mother/Guardian: Child lives with this person:   Yes   No   (circle one)
Full Name:
Work Phone/Cell Phone:
Father/Guardian: Child lives with this person:   Yes   No   (circle one)
Full Name:
Work Phone/Cell Phone:
Payment Information:
Payment Method:	Credit Card    Check    Cash    (circle one)
Credit Card Type:
Credit Card Number:
Name on Credit Card:
Expiration Month/Year:
Security Code:
Release:
I grant permission for a licensed physician and hospital to provide emergency care for the above-mentioned individual. Ambulance cost is my responsibility. To the best of my knowledge, the participant is in good health and is able to participate in the activity. I understand that while the recreation program staff makes the safety of participants its top priority, no recreational activity is without some inherent risk of bodily harm. In case of accidents, I release Upper Merion Township from all claims to personal injury and property damage which may result from participation in the above trip, activity, camp and other programs. The participant will abide by all rules and regulations set forth by Upper Merion Parks & Recreation relating to participation in the above trip and activity, including Upper Merion Area School District rules and regulations pertaining to illegal drugs, weapons and smoking. As an adult parent/guardian, I am responsible for all transportation to and from the activity or bus pick-up point. I have read and understood, and agree to the above items.

Signature:	Date:

Registration Methods: Online Mail or Fax Registration Form      Register in person	Payment: Cash (only when registering in person)      Check ("Upper Merion Township") Credit Card	Address: Upper Merion Park & Recreation      175 West Valley Forge Road King of Prussia, PA 19406	Fax: 610-265-6415	[Print Form]    [Close Form]