Parks Program - Registration 2011

8/7/2019 Parks Program - Registration 2011

1/5

Williamsport City Parks Program 2011YMCA Registration Form

My child(ren) will attend (circle one): Memorial Park Shaw Place

Start Date: _________________

Child(ren)s Name(s):______________________________________________________________

Address: ________________________________________________________________________

Phone: ____________________Age(s): ______ ; _______ Birth Date(s):_____________; _____________

Parent/Guardian Name: _____________________________________________________________

Address: ________________________________________________________________________

Phone: ____________________

Emergency Contact(s) if Parent/Guardian not available: Name: _____________________________________ Phone: __________________Relationship: _____________________________________

Name: _____________________________________ Phone: __________________Relationship: _____________________________________

Statistical Information This information is CONFIDENTIAL and only used for general statistical and

grant funding purposes. Providing this information does not affect your eligibility for the program.

Annual Gross Household Income: Childs Ethnicity:______ Under $10,000 ______ $40,001 - $50,000 _________________________ ______ $10,001 - $20,000 ______ $50,001 - $60,000______ $20,001 - $30,000 ______ $60,001 - $70,000______ $30,001 - $40,000 ______ Over $70,000

Does this family reside in subsidized housing (Section 8)? Yes No

Hold Harmless Agreement

I/We agree to indemnify and save harmless The City of Williamsport, YMCA, its officers, agents andemployees from and against all loss or expense (including attorney fees) by reason of liability imposed by lawupon The City of Williamsport and YMCA for damages due to bodily injury, including loss to thereof, arisingout of or in consequence of the performance of this agreement, providing such injury to persons or damage toproperty is due or claimed to be due to the negligence of the above name participant, its officers, employees oragents. A copy of this authorization shall be as effective as the original.

___________________________________________ ________________Signature of Parent/ Guardian Date

Form updated 4/11/08

Pay $5 Weekly ______

Pay in Full ______

Official Use Only


2/5

Medical Information

Allergies/Infections/Diseases

Hay Fever _____ Asthma _____ Bee Stings _____ Ear Infection _____Poison Ivy _____ Hepatitis _____ Penicillin _____ HIV Positive _____ Foods _____ Animals _____

Other _____ Additional or Specific Information: ___________________________________________________________________________________________________________________Physicians Name: ____________________________ Phone: _________________Do you carry hospital/medical insurance: yes _______ no ________Policy holders name: _________________________________________________Name and Identification number: ____________________________________________

__________________________________________ _______________Signature of Parent/Guardian Date

Field Trip and Transportation Permission Form

I hereby give permission for _________________________________________ to attend and be transported toand from all summer parks program trips as part of the City of Williamsport and YMCAs summer parksprogram. (This includes roller-skating, swimming, and other trips associated with the program.)

_____________________________________________ _______________Signature of Parent/Guardian Date

Authorized Pick Up Form

Please list up to four (4) people you authorize to pick up your child from the summer parks program.Remember to include carpool drivers, neighbors, co workers, relatives, or emergency situations. Theseindividuals must be able to present (upon request) valid picture identification. Please provide phone numbers aswell.

1. __________________________________ 2. _________________________________3. __________________________________ 4. _________________________________

___________________________________________ ________________Signature of Parent/Guardian Date

Authorized to Walk

By signing below, I authorize my child to sign themselves in and/or out as needed, and that they are authorizedto walk to and from the program without supervision.

____________________________________________ ________________Signature of Parent/Guardian Date



3/5

Photographic Release

I hereby give consent to The City of Williamsport and the YMCA to reproduce photographs or videos of mychild for advertising and publicity purposes.

______________________________________ ________________ Signature of Parent/Guardian Date

Religious/Church Consent

Several Christian organizations have offered to assist the City in providing recreation opportunities to the youthparticipating in the summer playground program. Some, but not all, activities will have a religious componentsuch as a Bible study, or the children may be offered the opportunity to attend Vacation Bible School. Bysigning below you are giving your child permission to participate in the Christian oriented activities. If you DONOT wish for your child to participate in these activities, DO NOT sign this section.

___________________________________________ __________________Signature of Parent/Guardian Date

Summer Parks Program Rules and Regulations

All participants MUST be registered.

Profanity is not acceptable.

Argumentative behavior/physical altercation is not tolerated.

No spitting, begging, snitching, or name calling.

Keep your hands, feet, and all other body parts/objects to yourself at all times.

Return all items to their original place.

Shirts and shoes must be worn at all times, and in an appropriate manner.

Proper shoes must be worn to use playground equipment.

Illegal drugs, tobacco, alcohol and WEAPONS OF ANY KIND are prohibited.

All problems will be handled by the Parks and Recreation/YMCA Staff ONLY.

Parks and Recreation/YMCA is not responsible for lost or stolen items

Parks and Recreation/YMCA has the right to refuse entrance to any individual. Any person entering the program may be searched at any time.

Severe weather(thunderstorm)-child MUST be picked up

The Parks Program discipline procedure is as follows:Manner of discipline will be determined by the Parks Directors according to the severity of the behaviorincluding (but not limited to) fighting, misbehaving on field trips, profanity, stealing, or not following the

rules set up by the staff. Possible disciplinary actions include:

Loss of activities/privileges

Verbal warning to the child and the parent will be notified in writing.

Parent/Staff conference

Suspension/Termination

I will help my child to understand and abide by the rules set by the staff, and realize that some children simply do notadjust well to a new setting.

I, the parent of _______________________ fully understand the summer parks program rules and will explain them tomy child and help to reinforce them to the best of my ability.

__________________________________ _________________Signature of Parent/Guardian Date



4/5

LUNCH PROGRAM INFORMATION

Lunch will be served to children who are registered and attend theprogram from 9am 3pm in its entirety, unless previous arrangementshave been made with the Recreation Coordinator or Site Supervisor. Due

to the nature of our lunch program, we must have the daily attendancecalled in by 9:15am. Any child that is not present by 9:15am will notreceive a lunch. In addition, there is only one lunch option each day - ifyour child does not like the lunch being served, they may bring their own.

By signing below, I understand that if my child(ren) is/are not present

by 9:15am, they will not be provided with a lunch.

___________________________ ____________Signature of Parent/Guardian Date

Special arrangements:____________________________________________________________________________________________________________

Parks and Recreation/YMCA staff are responsible for registered childrenin the parkbetween the hours of 9:00am and 3:00pm ONLY. If your childis present at the park before 9:00am or after 3:00pm, they will not besupervised.

___________________________ ____________Signature of Parent/Guardian Date

WHAT TO BRING? Water Bottle

Towel/Swimsuit

Sunscreen



5/5

YMCA Financial Aid Application

All requested documents must be returned with this application. Failing to do so will delay processing.

Todays Date: __________________ Date you need care to start: _____________________

Child(ren)s name(s) needing care: __________________________________ Age: _________

__________________________________ Age: _________

__________________________________ Age: _________

Parent(s)/Guardian(s): _________________________________________ Family Size: _______

Address: _________________________________________

_________________________________________

Home Phone: _________________________________________

Employer: ________________________________________________

Work Phone: ___________________________

Monthly Income Checklist (please check and submit all that apply for EACH household member):

_____ 4 consecutive paystubs if paid weekly

_____ 2 consecutive paystubs if paid bi-weekly

_____ Benefits (Social Security, Pension, etc.)

_____ Child Support / Alimony

_____ Other sources

I hereby acknowledge that the information submitted is complete and accurate.

Parent/Guardian Signature:_____________________________________________________


Parks Program - Registration 2011

Documents

Transcript of Parks Program - Registration 2011