SRC 2011 Summer Registration Form
Register by mail or in person Mon-Fri 8:30 - 4:30pm:
Please print this page and return
to:
Somerville Recreation, 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 |
___ Soccer Clinic $30 | ___ Volleyball Set - $20 w / $100 deposit |
| ___ Olympic Archery for Beginners - $20 | ___ Volunteer (priceless!) | |
| ___ Youth Water Awareness - $15 | Park ______________________ # Tickets _____________ | Area of Interest ______________________ |
| ___ Summer Basketball Night League - $15 / $150 | ___ Discount Movie Tix - $8.00 each | |
| ___ Tennis Mini-Camp - $25 | ___ Trip to Grounds for Sculpture - $20 | |
| ___ Summer Reading Club- FREE! | ___ Wedding Photo Session - $25 / 50 | |
| ___ National Night Out - FREE! | ___ Sports Bag Rental - Free | |
| ___ Arts & Crafts Club - FREE! | ___ Living Memorial - Fee TBD | |
| ___ Chess Club - $20 | ___ Camping Tents - $20 ___ Party Tent - $175 | |
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