Online Registration Form: Personal Euphoria

NO REGISTRATION WILL BE COMPLETED WITHOUT PAYMENT

Payment may be:
- dropped off in the white drop box located at Salem Town Hall
- mailed to Salem Town Hall, Salem Recreation, 270 Hartford Road, Salem, CT 06420 (check/money order (payable to the Town of Salem)
- made in person (please contact us to arrange a good time for you to come by!)
- made online via Credit Card, Debit or Electronic Check (transaction fees apply, minimum $2.00) or via

IMPORTANT: Transaction fees for payments made via Credit Card, Debit or Electronic Check will NOT BE REFUNDED should you choose not to participate in the program or the program be cancelled for any reason.

YOU MUST PRE-REGISTER FOR ALL PROGRAMS

CANCELLATION POLICY: No refunds will be given within two weeks prior to start of program if you choose not to participate in the program. A minimum of participants must be registered in order for program to be held. Payment will be refunded if program is cancelled. Please note that transactions fees for payments made via Credit/Debit Card or Electronic Check are non-refundable.

Name *

Address *

Town *

E-mail Address *

Phone Number *

Winter Session Classes

Barre-Pilates Fusion, Mondays, January 8-March 18, 5:45-6:30 pm, $65

Pilates, Tuesdays, January 9-March 26, 6:00-6:45 pm, $85

Cardio Strength, Wednesdays, January 10-March 27, 8:30-9:15 am, $85

Core Strength, Thursdays, January 11-March 28, 6:00-6:45 pm, $85

Spring Session Classes

Pilates, Tuesdays, April 16-June 18, 6:00-6:45 pm, $70

Cardio Strength, Wednesdays, April 17-June 19, 8:30-9:15 am, $70

Core Strength, Thursays, April 18-June 20, 6:00-6:45 pm, $70

TOTAL DUE * $

ASSUMPTION OF LIABILITY *

Participation in the activity may involve risk of injury. As a parent, guardian or participant, I am aware of these hazards and my or my child's ability to participate. I hereby agree to release, discharge and hold harmless the Town of Salem, its employees, contracted instructors and volunteers from the liabilities which may occur while participating in the activity. I understand that participation in any recreational or sport activity involves risk. I further understand that the Town of Salem does not provide accident/medical insurance for program participants. In addition, I give permission for the child(ren) to be treated by qualified medical personnel in the event that the above named parent/guardian can not be reached at the phone numbers provided. I also hereby give my permission to the Town to use any photographs, motion pictures, recordings, or any other media record as said activities in which I and/or said child(ren) appear for any lawful purpose. I am also aware that the transaction fee for payments made via Credit Card, Debit or Electronic Check will not be refunded should I/we choose not to participate in the program or the program be cancelled for any reason.

Full Name (Signature of Participant or Parent/Guardian, if participant is under 18) *

By typing in your full name, you acknowledge and understand the Assumption of Liability as stated above.

Date

Month

Day

Year

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Online Registration Form: Personal Euphoria