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2. 2026 COMMISSION FOR THE DISABLED/HANDICAPPED

   CLIENT APPLICATION

   We are in the process of updating our client information for the new 2026 year.  

   Even though you are a registered client, please update the form below. Thank you for your time.

   CLIENT INFORMATION:

4. Client Name*
5. Date of Birth*
   Date of Birth
7. Address
9. City*
10. State
11. Zip Code
13. Disabillity*
15. Allergies (Optional)
17. Emergency Contact Name
19. Emergency Contact Phone Number*
21. Group Home/Caregiver Email (if applicable)

23. PARENT/GUARDIAN INFORMATION:

25. Parent/Guardian Name *
27. Email Address*
29. Address (if different than above)
31. Phone Number (if different than above)

33. I understand that participation is at my own risk for Commission sports, programs and events. 

    I agree to hold harmless the Township of Jackson Commission for the Disabled/Handicapped 

    for any injury that I may incur. I also acknowledge that Jackson Township reserves the right 

    to utilize all photos and videos taken during recreation programs on our social media platforms.

    No personal information will be published without prior consent. 

    All Commission sponsored events are open exclusively to registered clients of the Commission and 

    their guests, they are NOT drop off events (excluding our Helping Hands program)
     

35. Please complete this form as soon as possible!

    If you have any questions, please call Karen Lundgren at 732-928-3334 or email KLundgren@JacksonTwpNJ.net

    
    

37. Please follow us on Facebook / Jackson Township Commission for the Disabled/Handicapped

Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field