240-777-8277

FAMILY MEMBER INFORMATION FORM: Please list all family members.

Last Name	First Name	Birthdate	Grade

Address:_________________________________________________________________

City:________________________________________ State:__________ Zip:__________

Home Phone: (_____)__________________ Work Phone: (_____)___________________

Signature Authorization Information:
When you register for classes using STARline, payment in full must be made by Visa or Mastercard. Access to your account will be via a Personal Identification Number (PIN) of your choice. This PIN will serve as your electronic signature. Your signature below is an agreement to authorize Montgomery County Department of Recreation to process your payment.

The County assumes no liability for injuries or damages arising from the results of participation. Due to the strenuous nature of some activities, the participant is urged to consult his/her physician concerning fitness to participate. All activities present inherent risks and hazards, which the participant assumes. I hereby approve of my child's participation in this Recreation program and consent to emergency treatment for my child on my behalf. To the best of my knowledge there are no physical or other conditions, which will interfere with my child's participation. I understand that the Department may use photographs/videos taken of Recreation programs.

______________________________________________________ Date: _____________
Cardholder/Parent Signature