Department of Recreation Swim Program Mail-In Registration Form

MAIL-IN REGRSTRATION ONLY

Mail form with Cheque/Money Order to:

Antigonish Town Recreation Dept.

274 Main Street, Antigonish, NS B2G 2C4

Parent Name ______________________________________________________________

Mailing address____________________________________________________________

Phone (H) ___________________________ (W) ________________________________

E-mail ________________________________ Family Physician

Any medical condition(s) _________________ Last level completed

Participants	AGE	LEVEL	1ST Time Choice	2ND Time Choice
1.
2.
3.

Enclosed is a cheque/money order in the amount of $__________ payable to the Town

of Antigonish Recreation Dept.

PLEASE DO NOT SEND CASH THROUGH THE MAIL.

I/we the undersigned agree not to hold the Town of Antigonish, St. Francis Xavier

University or any of its agents liable for any injuries sustained by any person registered

by me/us while a participant of this program.

__________________________ __ __________________

Signature of Parent/Guardian Date

PLEASE NOTE:

• Mail-in registration only will be accepted any time up to January 6, 2010
• You will be notified only if your first time choice is not available
• For further information contact Melanie at 863-2351 ext 221

THANK

YOU