(Please print and
submit it with your payment.)
Please
print
Name of Student: Sex: M F
______________________________
Name of Parent(s)/Guardian:
______________________________
Mailing Address (Please include town and zip code):
______________________________
Phone No: _________________________
Mobile Phone No: _________________
Email Address: _____________________
Age of Student: _______
Grade Completed: ___________________
School: ____________________________
Teacher’s Name:
____________________
Have you attended Summer Stages before?
Yes
No
Please specify session(s):
(Two-week sessions are in bold.)
Session 2________ July7 – July 11
Session 4________ July 28– August 1
Total
$_________
Emergency Contact: _________________
Emergency Phone No: _______________
Doctor’s Name: _____________________
Doctor’s Phone No:
_________________
Existing Medical Conditions, if any:
______________________________
Allergies: __________________________
Medication(s): ______________________
Physical Limitations (visual, auditory,
speech, muscular, etc.):
______________________________
Date of Last Tetanus Shot: ____________
Insurance Company: _________________
Policy/Group #__________I.D.
#________
T-Shirt Size (circle
one):
Youth: Small
Medium
Large
Adult: Small
Medium
Large
X-Large
XX-Large
Parent/Guardian Signature:
______________________________
Date:
_____________________________
Registration received: ________________
Registration confirmed: ______________
Fee Received: ______________________
Date: ____________ Check # _________
Balance Due: _______________________
Balance Received: ___________________
Date: _____________ Check #
________
Fees
$170 per one-week session if registration and payment are received before April 2, 2008 and
$185 thereafter. $340 per two-week session if registration and payment are received before
April 2, 2008 and $370 thereafter.
All refunds must be requested in writing by
May 7, 2008 and are subject to a
$25.00 processing fee. No refunds will be given if requested after May 7,
2008.
**All registrations are accepted on a FIRST COME FIRST SERVED basis and class size is STRICTLY LIMITED**
Forms and fees may be mailed to:
Brundage Park Playhouse
c/o Municipal Building
502 Millbrook Avenue
Randolph, NJ 07869
Incomplete registration forms will not be processed.
Registration forms without full payment will not be processed.
Forms and fees may be dropped off at the Brundage Park Playhouse on Carrell Road and at the following location during normal business hours 8:30am – 4:30 pm, Monday through Friday:
Randolph Senior Community Center
Calais Road
Randolph, NJ
Brundage Park Playhouse is a division of Randolph Township’s Department of Parks, Recreation and Community Services. Visit our website at: www.brundageparkplayhouse.org