SRC 2010 Summer Registration Form
Register by mail or in person Mon-Fri 8:30 - 4:30pm:
Please print this page and return
to:
Somerville Recreation, PO Box 399, 25 West End Ave. Somerville,
NJ 08876
Name: _________________________________________________________________________ Email Address: _____________________________________
Address ____________________________________________________________________ City / Zip Code________________________________________
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:
________________________________________________________________________________
In Case of Emergency Call:
Name _______________________________________________ Relationship to registered _____________________________
Address _________________________________________ Home# _____________________ Cell # ____________________
___ Fall Soccer - $45 / $30 |
___ Camping Tents - $20 ___ Party Tent - $175 | |
| ___ Olympic Archery for Beginners - $20 | Park ______________________ # Tickets _____________ | ___ Volleyball Set - $20 w / $100 deposit |
| ___ Youth Water Awareness - $15 | ___ Discount Movie Tix - $8.00 each | ___ Volunteer (priceless!) |
| ___ Summer Basketball Night League - $15 / $150 | ___ Trip to Grounds for Sculpture - $20 | Area of Interest ______________________ |
| ___ Tennis Mini-Camp - $25 | ___ Trip to Bronx Zoo - $45 / $35 | |
| ___ Summer Reading Club- FREE! | Contact Travelers Choice (908) 534-4224 | |
| ___ National Night Out - FREE! | ___ Wedding Photo Session - $25 / 50 | |
| ___ Family Fun Day Olympic Events - $20 | ___ Sports Bag Rental - Free | |
| ___ Arts & Crafts Club - FREE! | ___ Living Memorial - Fee TBD | |
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 activi-ties 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 im-pairment or undue discomfort if delayed. This authority is granted only after reasonable effort has been made to reach me.
Parent's (or Adult Participant'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 (for all registered participants) and is
subject to policy limits.
Please note: Somerville Recreation reserves the right to cancel, alter, 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