Leland O Mills ______
Date
Registration Fee Paid
YMCA ______
Staff Initials _________________
Child’s Name Address City/Zip____________
School______________________________Grade (Going in to) Age Birth Date
Mother’s Name Father’s
Name
Address Address____________________________________________
Home Phone Home
Phone________________________________________
Cell Phone ___________________________________
Cell Phone __________________________________________
Work Place Work Place__________________________________________
Work Phone Work Phone_________________________________________
Work Hrs: From_______________To_______________Work Hrs: From__________________To_________________
Emergency contacts, other than parents. (Local name and number, please):
Name Phone
Relationship
Name Phone Relationship
Liability waiver, Emergency medical authorization, and Field trip
permission.
On behalf
of this minor child, enrolled in the Tri-County YMCA of the Ozarks ADVENTURE
CAMP program, I hereby release the YMCA and its staff from all liability
relative to participation in the program, I hereby give my permission to the
YMCA Staff to obtain emergency medical care and transportation for my child
should the need arise. I understand that
I am responsible for any expense incurred for such care. I understand that activities may periodically
take place away from the usual program site.
I give permission for my child to participate in field trips and
off-site activities. I hereby give
permission for the Tri-County YMCA to use any photos or videotapes of my child
while involved in ADENTURE CAMP program for promotional purposes.
Child’s Doctor Phone
Child’s Dentist Phone
Parent or Guardian Signature Date
Any additional pertinent information may be written on the
back of this form.
++++++++++++++++++++++++++++++++++++USAGE
INFORMATION+++++++++++++++++++++++++++++++++++++
Three-Day Minimum Weekly
usage
Program
Hours: Monday
– Friday 7AM – 6PM
Days Child
Attending:
Drop-Off Time Pick-Up
Time
Monday ___________ ___________
Thursday ___________ ___________
Friday ___________ ___________
2010 Weeks Attending
Please
check all that apply:
June 1 - 4 _____ July 12 -
16 _____
June 7 - 11 _____ July
19 - 23 _____
June 14 - 18 _____ July
26 - 30 _____
June 21 – 25 _____ August
2 - 6 _____
June 28 – July 2 _____ August
9 - 13 _____
July 5 - 9 _____