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Thursday, April 12
Powerhouse
East Hanover, NJ
Members: $45
Non-members: $49
Return in person to Mosholu Montefiore Community Center: 3450 Dekalb Ave. Bronx, NY 10467
Childs Full Name_______________________________________________ Grade________ School_______________________________________________
Address______________________________________________________________________________________________Apt______ Zip________________
Mothers Name________________________________________________ Cell Phone # __________________________ Work #________________________
Fathers Name ________________________________________________ Cell Phone # __________________________ Work # _______________________
Emergency Name & Phone # ________________________________________________________________________________________________________
Please check here ( ) for April 11 Please check here ( ) for April 12
Total Member Amount Enclosed $_______ (Members have already paid the $245 Family Membership fee) Total Non-member Amount Enclosed $_______
I give permission for my child to participate in all activities and receive emergency medical care, if needed.
Unless we can replace your child for the trip, there will be no refunds.
Parents Signature____________________________________________________________________________________
____________________________________________________________