41 REGISTER: ONLINE QUALITYLIFEGRAFTON.COM PHONE 262-375-5310 FAX 262-375-5327 MAIL 675 N GREEN BAY RD GRAFTON WI 53024 1ST ALT. 1ST 1ST ALT 1ST ALT Gender Age OFFICE USE ONLY Conf. Wait List Class Level Session/Dates Time Fee Participants First/Last Name Program Name Choice Date of Birth REGISTRATION FORM Last Name Address City Home Telephone No. Email Address Father’s Name Cell Phone No. Mother’s Name Cell Phone No. RESIDENCY STATUS: † Village Resident † Town Non-Resident † Non-Resident Circle: Am Ex Visa MasterCard Discover F Check here if you would like an email confirmation. Credit Card # Expiration Date: V-Code Signature Please make checks payable to Village of Grafton, 675 N. Green Bay Road, Grafton Assume you are registered for all the programs you have signed up for. The Parks and Recreation Department will only notify you if a program is full or cancelled. Date Proc’d ________ $ $ $ TOTAL FEES MINUS CREDIT (if applicable) TOTAL Concussion waiver: As a parent and as an athlete it is important to recognize the signs, symptoms, and behaviors of concussions. By signing this form you are stating that you have read the concussion awareness information and understand the importance of recognizing and responding to the signs, symptoms, and behaviors of a concussion or head injury. F I am aware of the signs and symptoms of concussions (Please see Concussion Information Sheet http://www.village.grafton.wi.us/ DocumentCenter/View/8835 for full information.) Parent Name Parent Signature Date Micro Soccer Program Only F Micro Soccer I request my child to be on the same team as: *(first & last name) * Only ONE request may be granted. Requests are not guaranteed. F Please check if you would like to volunteer coach! Program name(s) Name Email