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RECREATION PROGRAM REGISTRATION
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Adult/Guardian
Name_____________________
Home
Address__________________________
City_____________
State_____ Zip_________
Home
Phone_________________
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City of Newport
225 SE Avery St.
Newport, OR
97365
(541) 265-7783
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Please list any medical problems and/or allergies
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Emergency
Contact: ___________________________________
Phone
#: ______________________Relationship____________
CASH________ CHECK________
VISA/MC_______
RECEIVED
BY: _____________________
DATE:
_________________
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The Newport Parks
and Recreation Department does not discriminate against any individual on
the
basis of that individual’s
age, race, sex, creed, color, national origin, or handicap.
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