SRC 2011 FALL WINTER Registration Form
Please Print all information
Register by mail or in person Mon-Fri 8:30 - 4:30 pm:
Please print this page and return
to:
Somerville Recreation, 25 West End Ave. Somerville,
NJ 08876
Name: _________________________________________________________________________
Email Address: __________________________________________________________
Address ________________________________________________________________________
City ___________________________________ Zip _________________ Phone# _____________
Home Phone# ___________________________________ Cell Phone # ___________________________________________
Male _____ Female _____ Age _____ Grade _____ School _____________________________________________________
Shirt Size: YL _____ AS _____ AM _____ AL _____ AXL _____
Medical Conditions (if any) Coaches/Instructors should know about:
________________________________________________________________________________
I can help coach __________________
In Case of Emergency Call:
Name _______________________________________________ Relationship to registered _____________________________
Address _________________________________________ Home# _____________________ Cell # ____________________
| ___ K-1-2 Soccer Clinic - $45 / 30 | ___ Carol Pager Memorial Softball Tournament - $200 | ___ Volleyball Set - $100 deposit / $20 weekend |
| ___ Youth Wrestling - $45 | ___ Radio City Show (Call for details) | ___ Zumba Excercise Class - $50 |
| ___ Tumble Tots -$40 | ___ Coach's Training Clinic - $30/Free | ___ Discount Movie Tix - $8 |
| ___ Coed Future Basketball All stars - $35 | ___ Chess Club - $20 | ___ Living Memorial - Fee / TBD |
| ___ Recreation Intertown Basketball - $45 | ___ Video Animation - $60 | ___ Camping Tents- $20 |
| ___ HS Boys Basketball - $400 (Team Entries) | ___ Let's Do Engineering - $50 | ___ Party Tent - $200 |
| ___ Volleyball - $375 / team | ___ Volunteer (priceless!!) | ___ Sports bag - Free |
| ___ Volunteer Coaches Background Check - Free | ||
I give my consent for my child to participate in the Somerville Recreation activities checked above. I understand there are special dangers and risks in these activities, including serious injury and death. I assume all risk of injury, damage and liability arising from these activities for my child.
As their parent/guardian, I herewith authorize the treatment of above child/children by a qualified or licensed medical doctor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only after reasonable effort has been made to reach me.
| _____________________________________________________________________ | ___________________ |
| Parent's Signature | Date |
Somerville Recreation provides secondary accident
insurance for all programs listed on this Registration Page.
This provides for a $25 deductible for all adult programs and no deductible
for youth programs and is subject to policy limits.
Somerville Recreation reserves the right to cancel, alter and/or supplement programs, or to limit registration to best serve all involved.
For inclement weather cancellation information please call the Somerville Recreation Cancellation Number 908-725-2300 x1010.