LEAP 2010 REGISTRATION FORM

Child’s Name: _______________________    Age: ____ Date of Birth: ______________

Parents/Guardian Name: ________________________ Relationship to child: _________

Address: ______________________________ City: __________________ State: _____

Email_________________________________

Contact Phone Number: ______________________ Cell Phone: ___________________

Emergency Contact Person: ___________________________Phone #: ______________

Relationship to Child: _____________________________________________________

Medical Concerns: ________________________________________________________

Allergies: _______________________________________________________________

Restrictions to activities: ___________________________________________________

Day Care Provider___________________________________Phone#:_______________

Brothers/Sisters___________________________________________________________

 I Grant my Permission for:

Out door play and playground equipment________news paper and promotional photo’s________ field trips___________ (INITIAL TO APPROVE: Parents will be apprised prior to all field trips)

PLEASE READ AND CIRCLE APPROPRIATE RESPONSES TO AID US IN ASSURING CHILDREN’S SAFETY DURING AND SURROUNDING LEAP EVENTS ACCORDING TO YOUR WISHES:

I will assume responsibility for my child whom  MAY/ MAY NOT leave the LEAP grounds unescorted by an adult at 2 p.m.

I  DO / DO NOT grant my permission for LEAP Counselors to dispense band aids, triple antibiotic ointment, calamine lotion, sunscreen, aloe and application of cold to treat minor scrapes, cuts, remove slivers, and attend to any minor injury occurring during LEAP or LEAP events. For the comfort, safety, and well being of my child during the LEAP program and events, I understand I will be contacted immediately for any injury outside of minor break in skin, or skin irritations.

I DO / DO NOT authorize LEAP staff to seek emergency Medical care if necessary on behalf of my child. I understand I will be contacted in case of any emergency situation involving my child.

I  DO  understand I am responsible for assuring my child brings a lunch from home.

By Signing below I agree to discharge the City of Le Grand, Pioneer Heritage Library, Parks & Recreation Board, the LEAP Director, staff, volunteers, and all its designees from any and all liabilities associated by and to my child’s person or property.

_________________________________                                          __________________

Signature of Parent or Guardian                                                                     Date

This program is free of charge through funding from the City of Le Grand, Parks & Recreation commission, Le Grand Pioneer Heritage Library, community Businesses & Grants. We are always accepting community donations through City Hall.

***Tax receipt are available. ***