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Mt. Hood Aquatic Center Summer 2010 Registration Form

Checks payable to: MHCC Please return with payment enclosed to: Aquatic Center Registration 26000 S.E. Stark St Gresham, OR 97030-3300

26000 S.E. Stark St. Gresham, OR 97030-3300 503-491-7243

Social Security Number (optional): (adult classes only)

Payment: Last Name

Check First Name

VISA

Mastercard

Initial

Amount enclosed: $

Birth date (Month/day/year)

Name on Card

Child’s Name

Street Address

City

Home Phone

State

zip

Work Phone

Card Number

Expiration Date

Signature

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Session

Class

Day(s)

Time

1ST Choice 2nd Choice 3rd Choice ETHINIC DATA AM – American Indian /Native American AS-Asian, Pacific Islander BL-Black, Non-Hispanic HI-Hispanic UN-Unknown WH-White, Non-Hispanic

HIGH SCHOOL COMPLETION D-Adult High School diploma G-GED H-High School Graduate N-Did not complete S-Still in high school U-Unknown

HIGHEST DEGREE LEVEL O-None 1-Other (short-term training) 2-1-year Certificate from CC 3-2-year Degree from CC 4-Bachelor’s Degree 5-Master’s Degree 6-Ph.D or Professional Degree

************************************************************************************************************************************************************************ Mt. Hood community College does not provide accident insurance for participants in swimming lessons. It is the responsibility of the parent to provide for this need. The parent/guardian, by signing this form, confirms that the above statement has been read and

understood.

Signature


/aquatics_form_summer