Littleton Parks, Recreation & Community Education Registration Form printable pdf download

Phone: 978-540-2490 / Fax: 978-952-6053

Littleton Parks, Recreation & Community Education Registration Form

PRIMARY HOUSEHOLD CONTACTS/PARENTS/GUARDIANS:

3 EASY WAYS TO

PARENT/PARTICIPANT NAME: _________________________

PARENT/PARTICIPANT NAME:_________________________

MAIL IN: Enclose a check, cash or

ADDRESS: ____________________________________________

SAME ADDRESS?

YES

credit card information with

registration form to: Littleton Parks

Recreation and Comm. Ed., 33

CITY: __________________ ST: ______ ZIP: ________________

IF NO, ADDRESS: ______________________________________

Shattuck St. PO Box 934, Littleton,

MA 01460

DATE OF BIRTH: _________/_________/_________

DATE OF BIRTH: ________/__________/__________

FAX: (978) 952-6053

Include credit card information in

WORK PHONE: (____) __________________________

WORK PHONE: (___) __________________________

space provided below.

CELL PHONE: (____) ___________________________

CELL PHONE: (___) ___________________________

WALK IN: Bring registration form

to the office at 33 Shattuck St.

HOME PHONE: (____) _________________ HOUSEHOLD MAIN E-MAIL ADDRESS: ________________________________

Littleton, MA

DOB

ACTIVITY NUMBER

PARTICIPANTS

M/F

Grade

ACTIVITY NAME

FEES

CODE # & SESSION LETTER

FIRST NAME

LAST NAME

DID YOU REMEMBER THE

COMPLETE IF

CC#

PARK&REC FEE OF $5.00

PAYING BY

PER PERSON? IF NOT, ADD

CREDIT

AMT OF CHARGE: $_____.___

EXP. DATE: _____/_____

CW2 Code : __ __ __

CARD

IT HERE.

(3# on back of card)

SIGNATURE AS IT APPEARS ON CARD: __________________________________________

#persons_____ x $5.00 = $______

NAME OF CARDHOLDER (printed): _______________________________________________

TOTAL FEES:

*We accept VISA, MASTERCARD, or DISCOVER*

Checks made out to: Town of Littleton

"Round Up" For Youth

FORM NOT VALID UNLESS SIGNED HERE BY PARENT/ GUARDIAN/ ADULT PARTICIPANT:

Recreation

Rounding up your

Participation in this program may involve risk of injury. As a parent, guardian, or participant, I am aware of these hazards and my ability to participate. In

program fee, helps

consideration for participation in the program(s) listed above, I hereby for myself, my heirs, executors and administrators waive and release any and all claims of

provide financial

damage against the Town of Littleton, its successors and assigns, employees, agents, and representatives for any and all kinds of injury, including but not

assistance for those

limited to personal injury and/or property damage suffered by my child, or myself, or my ward, while participating in this activity. In addition, I give my permission

TOTAL:

unable to afford the

for the child(ren) to be treated by qualified medical personnel in the event that the above named parent/guardian can not be reached at the phone numbers above.

program fee for youth

SIGNATURE: __________________________________________________________

DATE: ___________

activities.