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REGISTRATION FORM PLEASE RETURN WITH TWO SEPARATE PAYMENTS: ROSEVILLE REC ($50) AND RGBA ($150) <br />Name <br />Address <br />Parent's Name <br />CAMP Program # 2151.421 <br />Day AUG 7 -9 <br />Class Fee: $50.00 to Roseville Rec <br />$150.00 to RGBA (Check only) <br />Birthdate <br />City <br />E -mail <br />ON 61 - <br />Form of payment Check ❑ Cash ❑ <br />Visa El Mastercard El Exp Date <br />Credit Card # <br />Name on card <br />Tennessen Warning: The information requested on this registration will be used to verify eligibility and determine staff, facility and equipment needs. You /your <br />child's name, age, grade level, address, telephone number and health information will be provided to city staff, volunteers, the city attorney, insurer and auditor. <br />Although you are not legally required to disclose this information, failure to do so will prevent you /your child from participating in the program. <br />