HARFORD COUNTY DEPARTMENT OF PARKS AND RECREATION

NORTHERN DISTRICT
JARRETTSVILLE TAE KWON DO
 REGISTRATION FORM
(Registration is Open All Year Long - Sept. - July)

2009/2010 CALENDAR YEAR

JARRETTSVILLE RECREATION COUNCIL

NORTH BEND ELEMENTARY SCHOOL

Participant Name: ____________________             Program: Jarrettsville Tae Kwon Do

Address: __________________________              Registration Date: ______________

                ___________________________             Registration Fee (Individual):   $25.00

Home Phone: _______________________              Registration Fee (Family):       $50.00

Date Of Birth: _______________________              Registered By: _________________

Emergency Contact: __________________              Emergency Phone: ______________

                                                                (Name)                                                  

                                                                                            Cell Phone:________________
 

E-Mail Address:__________________________________
(To receive latest news, announcements and cancellations)

NOTE: REGISTRATION FEES ARE NOT REFUNDABLE!!

Should the instructor be aware of any physical conditions or allergies? _____________________________

Should the instructor be aware of any prescription drugs being taken? ______________________________

Where did you hear about Jarrettsville Tae Kwon Do? __________________________________________

I understand that I/my child will not be covered by any program insurance, and that I will

 not hold the program, instructor(s), recreation council, or it’s representatives responsible

for injuries received while participating in the above named program.

__________________                        _____________________

Parent’s signature       Date                                 Participants signature         Date

                                                                                (18 years or older)

DID INDIVIDUAL PARTICIPATE IN THE PROGRAM LAST YEAR?           YES______   NO______

IF ADULT VOLUNTEER ASSISTANCE IS NEEDED, WOULD STUDENT/PARENT(S) BE WILLING TO HELP

WITH THE PROGRAM? _______________________________________________________________