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Name:__________________________________ Phone:_____________________________
Address:___________________________________________________________________
__________________________________________________________________________
Payment: ($50 per session for West Goshen residents; $60 per session for non-residents): ______
Please circle session(s): Session II Session III
Medical Insurance Company:___________________________________________________
In case of Emergency, call (if different than home):____________________________________
I, the undersigned, intending to be legally bound for myself, my heirs, executors, administrators, and assigns, hereby waive and release any and all rights and claims for damages I may now
or hereafter have against West Goshen Township and its respective employees for any and all damages or injuries which may be sustained by me or my family arising out of participation in the above activity.
_________________________________ ________________________________
Signature* Date
* Signature of parent or legal guardian if participant is under 18.
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