Randolph Recreation Department Information Form

HOUSEHOLD INFORMATION: (please print all information legibly)

Todays Date: ___________
Household Last Name: _________________________
Resident: _____ Non Resident: _____
Household Email Address: (You may have more than one):_____________________________________________
__________________________________________________
PRIMARY HOUSEHOLD PERSON:

SECONDARY HOUSEHOLD PERSON:

Name_________________________________

Name_________________________________

Birthdate: ____________ Gender: _______

Birthdate: ____________ Gender: _______

Address: ______________________________

Address: ______________________________

City_____________ State_____ Zip_________

City_____________ State_____ Zip_________

Phone:

Phone:

Home: ___________________

Home: ___________________

Work: ___________________

Work: ___________________

Cell: ____________________

Cell: ____________________

Allergies: ______________________________

Allergies: ______________________________

Medication/ Medical Condition: _____________

Medication/ Medical Condition: _____________

Special Accommodations: _________________

Special Accommodations: _________________

T-shirt size Youth: XS S M L Adult: XS S M L

T-shirt size Youth: XS S M L Adult: XS S M L

EMERGENCY CONTACT: (Other than mentioned on this form)

Contact Name: _________________________________________ Relationship to household: _________________________
Phone: Home: ___________________

Work: ___________________ Cell: ____________________

FAMILY MEMBER INFORMATION: (children and/ or other people in household)

Name: ___________________________________

Gender ________ Birthdate ___________ Grade in Fall ___________

T-shirt size Youth: XS S M L Adult: XS S M L

Allergies ______________________________________________________
Medication or Medical Condition ___________________________________________________________________________
Name: ___________________________________

Gender ________ Birthdate ___________ Grade in Fall ___________

T-shirt size Youth: XS S M L Adult: XS S M L

Allergies ______________________________________________________
Medication or Medical Condition ___________________________________________________________________________
Name: ___________________________________

Gender ________ Birthdate ___________ Grade in Fall ___________

T-shirt size Youth: XS S M L Adult: XS S M L

Allergies ______________________________________________________
Medication or Medical Condition ___________________________________________________________________________

PLEASE ANSWER THE FOLLOWING QUESTIONS:

1. Would you like to subscribe to the E-Rec Newsletter? YES
NO
Email address to send it to: _____________________________________________________
2. Would you like information on Youth Scholarships?

YES

NO

Date Recd _______ Email Sent: ___________ Staff Initials _________

Randolph Recreation Department, 7 Summer Street, PO Drawer B, Randolph, VT 05060
Phone (802) 728-5433 x 18 Fax (802) 728-5818 Email: rec@randolphvt.org

Find us at Randolphvt.org, Front Porch Forum and Facebook at Town of Randolph Recreation