Military Parents Night Out Registration Form

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Military Parents Night Out Registration
Name of Child:___________________________________________________
Gender: Male / Female
Date of Birth:____________________________
Age:_______________
Address:________________________________________________________________________________________________________________________________
(Street)
(apt #)
(City)
(zip)
Parent/Guardian:__________________________________________ Date of Birth:___________________________
Parent/Guardian:__________________________________________ Date of Birth:___________________________
Home Phone:____________________________________
Cell Phone: ____________________________
Email:_____________________________________________
Work Phone:____________________________ Military Unit:____________
Authorized Person for Pick-Up and Emergency Contacts:
(Minimum of 3 contacts)
Name:_____________________________________ Number:_________________________ Relationship:____________________________
Name:_____________________________________ Number:_________________________ Relationship:____________________________
Name:_____________________________________ Number:_________________________ Relationship:____________________________
Please answer the following question.?
(If you circle YES, use form on reverse side to explain.)
Is your child physically and mentally able to participate in this program?
Yes
No
Does your child require special attention, medicine, or other routine?
Yes
No
Does your child have any physical conditions of which we should be aware?
Yes
No
Has the child had any illness of which we should take notice?
Yes
No
Is the child allergic to bee stings? If yes, is treatment required?
Yes
No
Is your child allergic to any medications? If yes, which medications?
Yes
No
Please initial and sign the following:
In an emergency, I authorize the physician selected by program staff to take necessary action
of treatment in the best interest of my child. (mandatory for participation)
__________(
Initial)
Media Release: I give consent for my child to be photographed or videotaped in program activities
that may be used in news releases or promotional brochures. I understand I will not be reimbursed
for such photographs or videotapes. The YMCA will also make every attempt to notify me of any
such use of the likeness of my child.
__________(
Initial)
Waiver (mandatory for participation): Participant specifically assumes all risks of injury arising out of his/her
presence on the premises of the Watertown Family YMCA use of the equipment or facilities and participation in
activities, whether on its premises or at another location, and for son/daughter, legal guardian and his/her heirs
and assigns herby waive, release and to hold free from all claims for damages the Watertown Family YMCA and
its officers, directors, members, employees or agents. I understand the risks and dangers involved in my son/
daughter participating in the programs and activities of the YMCA, and agree that he/she will not participate in
any activity that may injure themselves or others.
Parent/Guardian Signature:_________________________________________________
Date:__________________________________

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