Membership Form printable pdf download

TOWN OF PATTERSON

RECREATION CENTER

PO Box 278

65 Front St

Patterson, New York 12563

(845) 878-7200 Fax (845) 878-7232

Recreation Director

www.

Matthew Chibbaro

Membership Form

*Personal Information*

Cardholder Name: __________________________________ Age: ________ Birth Date: _________________

Phone Home: (____) ____-_________

Work: (____) ____-____________ cell: (____) ____-_________

Address: Street_______________________________ City: _______________

Zip: ___________________

Email Address: ___________________ Town of Residence: _____________ School District: ____________

Parents/Guardians Names: __________________________________________________________________

*Emergency Contact (must be someone other than member or parent): Name: ____________Phone :(____) ____-______________

*Medical Information*

I and or my child ______________________ is in good physical condition and has not had any serious illness

or operation since I/his/her last health examination that would interfere in I/his/her ability to participate in the

Patterson Recreation Programs. There is a current physical on file at school. Health insurance is absolutely

mandatory.

Family Physician: _________________________________________

Phone: (____) ____-_____________

Pediatrician: _____________________________________________

Phone: (____) ____-_____________

Medical Insurance Carrier: ________________________________

Policy #:______________________

Any Medical Concerns we should be aware of: yes /no please List: ________________________________

*Age Verification*

License/Permit#:_________ Passport#:____________ Birth Certificate: ___________ Other: ___________

*Membership Options*

(Please Circle Your Choice)

Patterson Resident

Single

$ 45

Non-Resident

Single

$ 70

Patterson Resident

Family

$ 80

Non-Resident

Family

$140

Patterson Resident

Student

$ 25

Non-Resident

Student

$ 35

Guest Fee

$ 5

Guest Fee

$ 5

Seniors – No charge

*Signatures*

In consideration for accepting this application I the undersigned, intending to be legally bound for myself, my heirs,

executor and administrators, waive and release any and all rights and claims for damages I may have against any and all

agents, chaperones, employees of the Town of Patterson and any other sponsors, their representatives, successors and

assigns for any and all injuries and/or damages suffered by me/my son/daughter in connection with this activity. I/ My

child are in suitable physical condition to participate in the activity specified in my application. In the event of injury I

authorize Patterson Recreation to arrange for medical care/transportation to a medical facility at my own expense.

However I understand that Patterson Recreation will not be held liable for any such medical care/transportation.

Signature of Participants Parent/Guardian: ____________________________________________________

_______________________________________________________________________________________________________________________

Office Use Only:

Application Date: __________ Signature: ____________________

hoto Taken: YES NO

Document Verification: Drivers License#:__________ Birth Certificate#:_____ Other Document/Number: _________

Office Use Only:

Today’s

Received

Entered

Amount: _______ Cash:

OR Check #:_______ Date:___________ Receipt# ____________ Initial: ___________ Initial/Date:_____________

As of: 5/24/2012

Office Use Only:

Today’s

Received

Entered

Amount: _______ Cash:

OR Check #:_______ Date:___________ Receipt# ____________ Initial: ___________ Initial/Date:_____________ Theatre Camp

2012

Membership Form

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