b'Portland Recreation & Aquatic Program Registration Form For Summer Camp Registration, visit www.portlandrec.com for summer camp registration: www.portlandmaine.gov/summercampregistration 212 canco road, suite A, Portland, me 04103|Phone & fax: 207-808-5400|recreation@portlandmaine.gov212 Canco Road, Portland, ME 04103 | Phone & Fax: 207-808-5400 | recreation@portlandmaine.gov Participants Name: ______________________________________________________ Male: Female: Last NameFirst Name Street Address: _________________________________________________________D.O.B:___/___/____City: ____________________________State:_____ Zip Code:___________Email:__________________________ Cell Phone: ____________________ Home Phone: ________________ Work Phone: ______________________T-Shirt Size (please circle one):YSYMYLSMLXLParticipants Name: ______________________________________________________Male: Female: Last NameFirst Name Street Address: _________________________________________________________D.O.B:___/___/____City: ____________________________ State:______ Zip Code:___________Email:__________________________Cell Phone: ____________________ Home Phone: ________________ Work Phone: ________________________T-Shirt Size (please circle one):YSYMYLSMLXLThe City of Portland Parks, Recreation and Facilities Department (the Department) is committed to providing interested participants equal opportunities in and access to its recreation programs The Department, as part of its mission, provides inclusive programming in an open and welcoming atmosphere. Qualified individuals with a physical or mental disability are encouraged to request reasonable accommodations to allow them to participate in public programs and services provided by the Department The Department will make reasonable accommodations for qualified individuals with a disability, so long as the accommodation does not fundamentally alter the nature of the program, pose a direct threat to others, or otherwise impose an undue burden on the City.Qualified individuals with a disability seeking an accommodation in order to participate in Department programs will be asked to complete a questionnaire in order to determine appropriate accommodations. My child _______________________needs a modification because of a disability to enjoy this program YES or NO (If YES, please request and complete the Inclusion Intake Form to help us plan for your childs needs. Inclusion Intake Forms can be found at the office on 212 Canco Road in Portland or by emailing recreation@portlandmaine.gov) Parent/Guardian(s) (if applicable): __________________________________________________ Male: Female: Last NameFrist Name Street Address: ________________________________________________________________D.O.B:___/___/____City: _________________________ State: _____ Zip Code:_____________Email:_____________________________Cell Phone: _______________________ Home Phone: ___________________Work Phone:_____________________ Emergency Contact:_____________________________________________________Relationship:______________Last NameFirst Name Cell Phone: _______________________ Home Phone: ___________________ Work Phone: ____________________'