Please check the appropriate box for registration.
Registration fee should be paid at the YWCA of Newburyport Pool Desk and NOT
at the Playground Program. You may not
sign your child up unless you have all information completed.
You may not bring your child until you have completed their
registration sign-up at the YWCA Pool Desk.
Please note: Days
and times are subject to change while we wait for approval.
ÿ
$30 registration fee paid to the YWCA, at 13 Market Street, Newburyport, MA
ÿ
I wish to have the registration fee waived for the following financial reasons:
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Name of Child: __________________________ Date of Birth:
_____________________
Your
child(ren) must be 6 years old BEFORE THE START of the program.
Address:
________________________________________________________________
(street)
(town)
(zip)
Phone: (H) _____________________________
(W) ____________________________
Emergency Numbers to called: (between 8:30am-12:30pm)
1. Name ______________________________ Phone
____________________________
2. Name ______________________________ Phone
____________________________
3. Name ______________________________ Phone
____________________________
4. Physician: __________________________ Phone
_____________________________
Please circle the Playgrounds your child(ren) will be
attending below:
WOODMAN
CASHMAN
NOCK MIDDLE SCHOOL
Monday and Wednesday
Tuesday and Thursday
Meeting place for Friday field trips
IF IT BEGINS TO RAIN OR
THUNDER DURING THE PLAYGROUND PROGRAM, PARENTS ARE TO PICK THEIR CHILD(REN) UP
IMMEDIATELY.
In consideration of this registration
being accepted, I hereby release the Newburyport YWCA Summer Playground Program
and the City of Newburyport, their agents, servants and employees from all
liability in the event of injury received during participation in the said
Summer Playground Program.
___________________________________
Date
Parent/Guardian Signature
In event of serious accident or injury, I
give my permission for my child to be taken to the nearest hospital for
emergency treatment.
____________________________________
Date
Parent/Guardian Signature
All children are to be
picked up by 12:30 PM otherwise a late fee WILL be imposed to whoever picks up
your child(ren).
NEWBURYPORT YWCA HEALTH
STATEMENT & MEDICAL FORM
Name ________________________________________ Date:
_______________
Address ___________________________________________ Phone:
_________
No.
Street
Town
Zip
Date of Birth: ___/___/___
Age: ______
Emergency Name & Phone #
_________________________________________
Physician: ______________________________ Phone:
____________________
Dentist: ________________________________
Phone:____________________
Check (Ö)
if you have or have had any of the below conditions.
( ) Have diabetes?
( ) Have epilepsy?
( ) On any
medications?______________________________________________
( ) Any physical problems? (back, knee, etc.)
_____________________________
( ) Dieting? If so, what diet?
__________________________________________
( ) Any chronic ailments? (asthma, etc.)
_________________________________
( ) Heart condition?
( ) Do you smoke? If so, how much?
___________________________________
( ) Seen a doctor within the last year for any reason?
( ) Had surgery within the last year?
( ) Other, Please explain:
_____________________________________________
Are you accustomed to regular exercise?
( ) Yes ( ) No
Are you accustomed to vigorous exercise?
( ) Yes ( ) No
I give permission for the YWCA to photograph and possibly
publish my child’s picture. ( )
Yes ( ) No
To the best of my knowledge, the above person is physically
able to take part in YWCA physical programs.
The YWCA reserves the right to request a medical examination if deemed
necessary.
I, the undersigned, sign this statement in lieu of providing
the YWCA with a statement from my/their doctor indicating an appraisal of
my/their status of health.
I, the undersigned, absolve the YWCA from all responsibility
for any injury or any illness suffered or sustained by the above person during
any YWCA activity or of any illness suffered during or after my/their
participation.
_______________________________________
________________
Signature
(Parent/ Guardian if applicable)
Date
