Registration Form - Alternative Leisure Company printable pdf download

A.L.C.

AND

RIPS

NLIMITED

RESENTS

A.L.C.

Registration Form

Trip Name:______________________________________________________________

Date of Trip: ______________________________________

Trip Cost:_________________

** PLEASE PRINT CLEARLY AND FILL OUT COMPLETELY **

Name: _____________________________________________________________ _______ Date of Birth: ________________________

Home Address:_____________________________________________________________ Email: ___________________________________________

City:

State:

Zip:

Telephone:_________________________________

*CALL THESE NUMBERS FOR ANY CHANGES OR EMERGENCIES*

Contact Name #1_________ ________________________________________ _________

Phone ____________________ _________

Contact Name #2 _________________________________________________ _________

Phone___ _________________ _________

Billing Address if Different from Home:

Attn:_______________________________________________ Agency:_________________________________________________________

Billing Address:___________________________________________City:____________________________________ State:________ Zip:___________

Tel. :

___________

Email: ___________________________________________________________

Locations: Bedford Bruegger’s Bagels, Brockton Dunkin Donuts @ West Gate Mall (min. 2 people), Concord Papa Razzi Restaurant, West Concord Carter

Center (min. 2 people), Harvard, MA Dunkin Donuts (Rt. 2: min. 2 people), MBTA (Newton) Riverside, Milton Dunkin Donut’s, Natick Red Roof Inn, New-

ton Bruegger’s-Auburndale Plaza, Peabody Life Center (min. 2 people), Stoneham “99” Restaurant, Watertown Dunkin (min. 2 people) Overnight trips may

meet at airport or other locations.

*Meeting locations are determined one week prior to each day trip and are based on client locations and required minimums.

I hereby give my approval for my/my child’s participation in the Recreation Program and do hereby waive, release, absolve, indemnify, and agree to hold

harmless Alternative Leisure Co., Inc., Trips Unlimited, and their directors and instructors from any claim arising out of injury to me or my child. I also

consent to allow medical treatment in the case of an emergency. I give permission for photographs of my child/self to be used in future A.L.C. publications.

Parent/Guardian Signature

Trip Fee:

$___________

Client Signature (if over 18)

Coupon /E.B. used:

$___________

‫ ‮‬ Visa  ‫ ‮‬M aster Card ‫ ‮‬ American Express

Credit Applied:

$___________

Card No

Exp.

Total Amount Paid: $__________