Required fields are marked with asterisks (*)

Township of Elizabethtown-Kitley Swim Program:

Session #:

Session 1

Session 2

Session 3

Level:

Name:

Address:

Elizabethtown-Kitley Resident?:

Yes

If no, please enter the name of the municipality:

Home Phone Number:

Cell Phone Number:

Email Address:

Date of Birth (of applicant) MM/DD/YYYY:

Health Card Number:

Emergency Contact (Name):

Emergency Contact (Number):

Parent/Guardian or Participants Consent:

I agree not to hold and save harmless the Township of Elizabethtown-Kitley, the Township of Elizabethtown-Kitley Recreation Committee or its agents of all responsibility for any accidents, injuries, losses or damages which may occur as a result of named participant involvement in the planned activities.

Parent/Guardian (if under 18) or Participant:

Parent/Guardian's Name:

Signature:

Clear

Date of Signature: