Preschool Registration Form printable pdf download

Gloucester Township Recreation Department

Preschool Registration Form

Program Name: ____________________________________

Location: ________________________

Child’s Name: ___________________

Age: ____ DOB: ___

______

Additional Child: ___________________________

Age: ____ DOB: __

_______

ADDRESS: _____________________ City, State, Zip: _________________________ Phone: ________________

Email:

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: _______________

(optional)

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: ______________________

PLEASE READ AND SIGN BELOW:

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: _____________________

Preschool Registration Form