Department of Recreation Track & Field Program Mail-In Registration Form

MAIL-IN REGISTRATION ONLY

Mail form with Cheque/Money Order to:

Antigonish Town Recreation Dept.

274 Main Street, Antigonish, NS B2G 2C4

Parent(s) Name ____________________________________________________________

Mailing address__________________________________________________________

Phone (H) ___________________________ (W) _______________________________

E-mail _______________________________ Family Physician ___________________

Any medical condition(s) ________________

Childs Name	Age
1
2
3

Enclosed is a cheque/money order in the amount of $ _________ payable to the Town of Antigonish Recreation Department.

PLEASE DO NOT SEND CASH THROUGH THE MAIL.

I/we the undersigned agree not to hold the Town of Antigonish, 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