Mayor Bert Steinmann Presents

Mayor Bert Steinmann Presents

Mayor Bert Steinmann presents…

Lunch with Santa Claus

Saturday, December 17th, 2016

2:00pm – 4:00pm

Ewing Senior & Community Center, 999 Lower Ferry Rd.

Send completed forms back to

Ewing Recreation Dept. 999 Lower Ferry Road, Ewing, NJ 08628

Or register online at

Please respond by Wednesday, December 11th,

Will be limited to first 100 children who register and a donation

for the local food pantry for families in need, animal shelter or a monetary contribution to Signal 22 Canteen who provide food to 1st responders

Name of Parent/Guardian: ______

Address: ______

Email: ______

Home: ______Cell: ______Work: ______

Medical/Allergies: ______

Name of Child: ______Age: ______

Name of Child: ______Age: ______

Name of Child: ______Age: ______

Name if Child:______Age:______


I give permission for my child, and/or myself to participate in thisprogram. I understand that the Ewing Township carries no accident insurance for this program. I understand that the risk of injuryfrom the activities involved in this program is significant, including the potential for permanent paralysis and death. I knowinglyand freely assume all such risks, both known and unknown. It is the responsibility of individuals participating in a Town class oractivity to notify in writing, any physical limitations that may limit or impair their activity in the program for which they areregistered and the Town will make reasonable accommodations. I do herby, for myself, my children, my heirs, executors and assigns,hereby release and hold harmless the Township of Ewing, their officials, officers, agents and/ or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and leasers of premises used to conduct the event, with respectto any and all injury, disability, death, or loss or damage to person or property, whether arising from the negligence of the release’s or otherwise, to the fullest extent permitted by law. I am of lawful age and legally competent to sign this agreement for and in behalf of the participants.

Furthermore, I give consent for emergency treatment. The undersigned also agrees and gives permissionfor their likeness, or the likeness of their child, to be photographed or videotaped and that such image may be published in an outletused to promote or publicize Ewing Township Community Activities. I understand that any omission or misstatement regardingresidency on this registration form shall be grounds for removal from the event regard- less of the time elapsed.

Signature: ______Date: ______