Name: __________________________________________________

Parent's Name (if applicable):__________________________

Age: _______  Grade: ________Date of birth______________

Course Name:  _________________________________________

Time:  _________________    Fee:  $________

Course Name:  _________________________________________

Time:  _________________    Fee:  $________

Course Name: __________________________________________

Time: _________________     Fee: $________

Address:  _______________________________________________

Town:  ________________________  Zip Code:  ____________

email address: _________________________________

Home Phone:  _____________  Work Phone:  ____________

Medical Concerns:  ____________________________________

Emergency Contact:  __________________________________

                    Phone:  __________________________________

Parent’s Signature (children’s programs):

__________________________________________________________

Please Make Check Payable to:

Chebeague Recreation Center

382 North Road

Chebeague Island, ME 04017