Kids Blast Jr. After Kindergarten Program

Kids Blast Before and After School Program

Registration Form – Complete registration form for each child and return to the Recreation Department.

Please indicate the program choice and times.
Kids Blast Jr. _______

Weekly ________ A..M.(11:30 – 3 p.m.) Only _____

A.M.& P.M.(11:30 – 6 p.m..) _____

Individual Days - List ____________________________________

Kids Blast _______

Weekly ________ Part-time A.M.(7:30 - 8:30 a.m.) Only _____

A.M.& P.M. _____ P.M. On.ly ______

Individual Days - List ____________________________________

 

Please print clearly.

Child’s Name:____________________________________ Grade Fall 2003____________ Age ______

Address: _________________________________________________Home Phone ________________

Parent’s Names _______________________ Mom's Work # ____________ Dad's Work # ___________

Child's Physician ________________________________________ Phone # ______________________

List any Medical conditions\allergies: _____________________________________________________

In case of an emergency, may we transport via ambulance? Please circle Yes No

Please list anyone who does not have permission to pick up your child (If this is a biological parent, a copy of the court order must accompany this form). ______________________________________________

My child is in good health and has my permission to participate in this program and on field trips. I understand that various activities during camp present a risk of injury.

______________________________________________
Parent/Guardians Signature