Northern York Community Services, Inc. (NYCS)
Registration Form
Mail to: NYCS, Inc., P.O. Box 77, Dillsburg, PA 17019
For more information: E-mail - Carolyn@northernyork.org
Family Last Name: _______________ Parent/Guardian Name: __________________
Address: __________________ City:____________________ Zip: ______________
Home Phone: ______________ Work: _________________ E-mail: _____________
Municipality (circle one): Carroll Dillsburg Franklin Twp. Franklintown
Monaghan Warrington Wellsville Other: _____________
Special Considerations (handicap accessibility, allergic reactions)? ________________
Emergency Contact (Name & Number): ___________________________________
Participant's NameFirst, Last |
M/F |
Birth Date |
Age |
Program Title/Description/Date |
Fee |
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Subtotal: Checks payable to: Other: NYCSF Donation: Total: |
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Signature of a parent or legal guardian is required for youth registrations. All adult participants must sign below for adult programs.
Northern York Community Services, Inc.(NYCS, Inc.)/Northern York Community Center activity programs and facilities are made available and utilized on the basis of “use at your own risk”. I hereby assume all possibilities of an accidental injury at my own risk in connection with this program and realize that NYCS, Inc.does not cover my participation in this program with an accidental insurance policy. I realize that I must use my own personal accident insurance coverage, if I have such, for any type of claim involved. Otherwise, any such expenses shall by my sole responsibility.
_____________________________________ ______________________
Participant Signature Date
_____________________________________ ______________________
Parent/Guardian Signature (if under 18)
Date
YES, I would like to volunteer. Name: ____________Program: _____________