TOTAL____________One form per household
Program Registration Form
.
Please print out, complete and mail with your payment. Make checks payable to the Village of Mt. Horeb.
Current participants only need to fill out BOLDED areas unless info has changed. If over 18, fill in your own information, not your parents information.
.
Family last name ________________________ Mailing Address______________________________________
City & Zip ________________________________________ Home Phone ______________________________
E-mail address(for rec dept. use only) __________________________________________________________
Father's name ___________________________ Work Phone ________________ Cell___________________
Mother's name ___________________________ Work Phone ________________ Cell___________________
Check one: Resident (within the school district boundaries) ________ Nonresident _________
T-shirt size Youth: small (6/8) ______ medium (10/12) ______ large(14/16) ______
(if applicable) Adult: small ______ medium ______ large ______ x-large ______
|
Participants First Name |
M/F | Age |
08-09 Grade |
Date of Birth | Program Name | Program # |
Level/ Sess |
Fee |
|
|
||||||||
|
|
||||||||
|
|
Please make checks payable to the Village of Mt Horeb If non-resident add $5.00 per program_________
Late Fees (if applicable)____________
*Scholarships are available for persons with financial hardships Scholarship Donation*____________
TOTAL____________
.
I
request my child to be on the same team as: _________________________________*
(first & last name)
* Requests are only for team sports. Only ONE request may be granted & requested individual must request you. Requests are not guaranteed, but we will do our best to grant them if it is at all possible.
.
Please check if you can volunteer ______ Which program(s) ________________________________________
Name of volunteer ____________________________________
Coach t-shirt size: S ___ M ___ L ___ XL ___ XXL ___
.
.
Special Needs ______________________________________________________________________________
.
Waiver of Liability
The Village of Mt Horeb is not responsible for any injuries sustained as a result of participation in any department sponsored activities, or while using departmental facilities. the Mt Horeb Recreation Department recommends that anyone enrolled in a program or using facilities make provisions for adequate insurance coverage. I understand program fees are not refundable.
.
Signature ___________________________________________________ Date ___________________
Assume you are registered in all the programs you have signed up for. If you would like a confirmation, please include a self-addressed stamp envelope. The Mt. Horeb Recreation Department will only notify you if a program is full or cancelled.
For office use: Cash_______ Check_______ #_________ CC________ VISA / MASTERCARD / AM. EXPRESS