Winter Spring 2017
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
Online<br />
GetintoGEARS.org<br />
Registration Information<br />
<strong>Winter</strong>/<strong>Spring</strong> <strong>2017</strong><br />
Email: GEARS@GetintoGEARS.org<br />
Phone/Fax<br />
Call us at 717.367.0355 or fax to 717.367.4138.<br />
Don’t forget to have your Visa, MasterCard, American Express or Discover<br />
card ready.<br />
In Person<br />
Drop by our office (lower level of the E-town Middle School).<br />
Mail-In<br />
GEARS, 600 East High Street, Elizabethtown, PA 17022.<br />
Register<br />
NOW<br />
Parent/Legal Adult Guardian Name<br />
GEARS<br />
<strong>Winter</strong>/<strong>Spring</strong> <strong>2017</strong> Registration Form<br />
Name_________________________________________Birthdate_____________________<br />
Address___________________________________ Email Address_ ____________________<br />
City_ _________________________ Twp/Boro: E-town Boro WDT MJT Conoy NR<br />
Home #___________________ Work #_ __________________ Cell #_ __________________<br />
Emergency Contact Name_ _____________________ Phone #_ _______________________<br />
Everyone listed here must reside at the same address otherwise use a separate form for each address.<br />
Individuals must provide their own accident insurance.<br />
Participants Name Birthdate Sex Program Title Session/Class Fee<br />
Payment Method (Circle One) Visa MC Amer Exp Discover Cash Check From Account<br />
Credit Card Payment Authorization Credit Card Number______________________<br />
________________________________<br />
Authorized Signature (as shown on credit card) Expiration Date__________________<br />
www.GetintoGEARS.org Page 23
Change language