Preschool Registration Form


Gloucester Township Recreation Department
Preschool Registration Form
Program Name: ____________________________________
Location: ________________________
Child’s Name: ___________________
Age: ____ DOB: ___
Additional Child: ___________________________
Age: ____ DOB: __
ADDRESS: _____________________ City, State, Zip: _________________________ Phone: ________________
Father’s Name: __________________ Father’s Workplace: _________________Additional/Cell Phone ________________
Mother’s Name: __________________Mother’s Workplace: _________________ Additional/Cell Phone ______________
Emergency Contacts: (other than parent, whom child can be released)
Name #1: _____________________ Phone: ____________________ Relationship to child: _______________
Name #2: _____________________ Phone: ____________________ Relationship to child: _______________
My child is allergic to: ________________________________________ Child’s Doctor & #: _________________________
Please include any information about your child that you feel would be beneficial (Include any medications that your child is currently taking) :
I hereby give my approval for emergency medical care for my child.
Parent/Guardian Signature: _______________________________________________ Date: ______________________
I, the parent/guardian of the participant listed above, so hereby consent and allow his/her participation in the above program. I agree to
indemnify and hold harmless the Township of Gloucester, its agents and employees from any injuries or damages I or my child may
sustain while participating in this program. I also understand, should I need a refund for any reason, that I need to request it
before 20% of the program is done, minus a $10.00 processing fee, and it may take up to 30-45 days to process a refund. All
returned checks are subject to a $25.00 fee.
Parent/Guardian Signature: _________________________________________ Date: _____________________


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