THE
ONALASKA COMMUNITY YOUTH CENTER(OCYC)
Registration
Information:
(Please
print legibly.)
Name:
__________________________________________________________
School:
___________________________
Date of Birth: ____/____/____
Age:
__________
Grade: __________
Sex: __________
Address:
_________________________________________________________
Home
Phone: _____________________________________________________
Name
of Parent or Guardian: _________________________________________
Parent’s
Work Phone: ______________________________________________
Name
and phone number of persons to be contacted in case of an emergency (other than parents):
Name:
_________________________________ Phone:
_______________
Relationship:
____________________________________________________
Parental
Permission and Medical Release:
I,
the parent or legal guardian of ___________________________________ (my child), authorize
The OCYC volunteer staff to obtain medical care for my child in the event such care is
necessary. I understand that, if possible, I
will be contacted in the event my child requires medical attention. I grant to a licensed health care provider or
accredited hospital permission to perform any medical and/or surgical procedures that are
essential for the treatment of my child and agree to be responsible for payment of such
care. I release the OCYC volunteer staff and
its board members from any damages, liability, or loss resulting from their securing in
good faith medical care for my child.
I
am hereby giving permission for my child to use The OCYC.
I understand that The OCYC is a drop-in recreational facility and that my
child will be allowed to come and go from the premises at will given that they (my child)
signs in and out before doing so. My child has
been made aware of the OCYC expectations and has agreed to fulfill those expectations by
terms of this agreement.
Parent
or Guardian Signature: _______________________________________________
Date
_____________
I
give permission for The OCYC to use photographs of my child for publicity purposes.
Yes:
________
No:
__________
I
give my permission for my child to attend the Grand Opening Celebration at the OCYC, June
14, 2007; and if necessary to be transported by school bus the youth center’s
location. I am aware that the youth center
closes at 8:00 pm Thursday night and will have picked up my child by closing time.
Parent
or Guardian Signature__________________________________Date___________ |
