Gloucester Township Recreation Department Preschool Registration
P.O. Box 8, Blackwood, NJ 08012    Tel: 856-435-5734/Fax: 856-782-8962

Program Name: _____________________________________________      Location: ________________________                        
Child’s Name: ____________________________   Current Grade: ____   School: _______________   Age: ____   DOB: _________
Additional Child: _________________________  Current Grade: ____   School: ________________  Age: ____   DOB: _________

ADDRESS: _______________________________ City, State, Zip: _____________________________ Phone:________________

Father’s Name: ________________________ Father’s Workplace: _______________________ Work Address: __________________
City/State: _______________________ Work Phone:   (       )                           Additional/Cell Phone (optional): ________________

Mother’s Name: _________________________ Mother’s Workplace: ______________________ Work Address: _________________
City/State: ______________________ Work Phone: (        )                                  Additional/Cell Phone (optional): ______________

Emergency Contacts: (other than parent, whom child can be released)
              Name #1: _____________________________ Phone: ____________________ Relationship to child: _______________
(optional) Name #2: _____________________________ Phone: ____________________ Relationship to child: _______________

My child is allergic to: ____________________________________________ Child’s Doctor: _______________________________
Please include any information about your child that you feel would be beneficial (Include any medications that your child is currently taking) :

______________________________________________________________________________________________________________

I hereby give my approval for emergency medical care for my child.
Parent/Guardian Signature: _______________________________________________   Date: ______________________

PLEASE READ AND SIGN BELOW:

I, the parent/guardian of the participant listed above, so hereby consent and allow his/her participation in the above program. I agree to indemnify and hold harmless the Township of Gloucester, its agents and employees from any injuries or damages I or my child may sustain while participating in this program. I also understand, should I need a refund for any reason, that I need to request it before 20% of the program is done, minus a $10.00 processing fee, and it may take up to 30-45 days to process a refund.

Parent/Guardian Signature: _________________________________________ Date: _____________________