On-Line Recreation Registration

Office Closed on Monday, February 13th

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CITY OF PERTH AMBOY
Office of Recreation
Registration Form

Name of Program:

Date:

Child's Name	Date of Birth	Age	Sex	Fee Paid (if applicable)





Money Order #:	Money Order #:: Make money orders payable to: City of Perth Amboy, Mail payment or Visit Office		Amount Due
Parent's Name:			Choose Phone
Address:			Phone 1	The phone number is not complete
City:			Choose Phone
State:			Phone 2	The phone number is not complete
Zip Code			Email:
How did you hear about the program?

EMERGENCY CONTACT: (Must be filled in or child will not be permitted to participate)

Name:	Relationship
Address:	Choose Phone
City:	Phone 1:	The phone number is not complete
State:	Choose Phone
Zip Code	Phone 2:
	Medication
	If Medication Yes
	Does child have seizures?
	If yes, how often?

Do you have any additional comments that would help us get to know your child?

HOLD HARMLESS AGREEMENT:

I, the undersigned, give my permission and assume all responsibility while I or my child(ren) take part in recreation programs conducted by the Perth Amboy Department of Human Services, Office of Recreation. I agree to hold the City of Perth Amboy, City Employees, including, but not limited to volunteers, invitees, consultants and trainers, harmless as to any and all claims arising from any injury or illness sustained during or as a result of participation in the above referenced program or activity. I also consent that the City of Perth Amboy may use the name, image voice and/or likeness of my child in any photograph, newsletter, television program or other media/Web Site promoting or advertising the City of Perth Amboy’s Office of Recreation Programs.

Parent/Guardian Signature:

Parent/Guardian Signature: :: Please Print Your Name and Last Name as a Signature

Enter Code: