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Name _______________________________ Age ______ Phone __________

Address ________________________________________________________

Birth Date _______________ Sex ________ Grade Completed _____________

Circle the municipality where you reside:


Bedford Borough Bedford Township
Colerain Township Cumberland Valley
Harrison Township Hyndman Borough
Londonderry Township Manns Choice Borough
Rainsburg Borough Snake Spring Township


 

Please place an X next to your selection. Grades are based on the grade just completed.

 

Week of

Boys 1-4

Boys 5-8

Girls 1-4

Girls 5-8

6/10 6/14

 

___ Soccer

 

___ Golf

___ Swimming

 

___ Cheerleading

 

___ Golf

___ Swimming

 

6/17 6/21

___ Bowling

___ Baseball

___ Swimming

___ Soccer

___ Cooking I

___ Bowling

___ Swimming

6/24 6/28

___ Swimming

 

___ Bowling

___ Baseball

___ Basketball

___ Cooking II

(Cooking I required)

___ Cheerleading

___ Bowling

7/8 7/12

___ Swimming

___ Football

___ Soccer

___ Tennis

___ Arts & Crafts

___ Soccer

___ Cooking I & II

 

7/15 7/19

___ Basketball

___ Wrestling

___ Wrestling

___ Tennis

___ Swimming

___ Volleyball

___ Arts & Crafts

___ Tennis

7/22 7/26

___ Football

 

___ Basketball

___ Golf

___ Swimming

___ Basketball

___ Golf

 

We, the parents of __________________________________, have seen that our child has been examined by a physician and is in sound physical health. We agree to provide accident insurance through our private company to cover our child as the Bedford Area Board of Parks and Recreation will carry no insurance. We are aware and understand there are certain assumed risks involved with our childs participation in the above circled activity, and we will not hold the Bedford Parks and Recreation and/or any of the sponsoring agencies liable for any personal loss or injury that may occur. We are aware that the Bedford Board of Parks and Recreation does NOT sanction or sponsor any competition that involves children from outside the municipalities listed below.

 

Your signature is also needed for release of photo for use on the web site, no names will be listed. Please sign here if you do NOT want your child's photo used on the web site.

 

Declining photo release: Parent/Guardian Signature _______________________________________

 

Please list any allergies or special medical conditions that may exist so the best possible care may be given to your child in an emergency. _______________________________________

 

If your child has registered for swimming, please answer the following questions to assist us in proper placement in a swimming class.

1). How many years has your child taken swimming lessons? __________________________

2). What is the highest-level swimming course you child has passed? ____________________

 

__________________________________________ ______________________

Parent/Guardian Signature Date

 

Webmaster Mary Dibert 5/7/2002