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2021-2022 CHAMPS Registration Form
This year we will be returning to the YMCA, Beardsley & Memorial Library and American Mural Project. We will host programs at all three schools as well!
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Email *
Student Name (Last, First) *
Grade (Fall of 2021) *
Parent/Guardian 1 (Last,First) *
Parent/Guardian 1 Phone Number *
Parent/Guardian 1 Email Address *
Parent/Guardian 2 (Last, First)
Parent/Guardian 2 (Last, First)
Parent/Guardian 2 Email Address
Emergency Contact other than Parent/Guardian (Last,First) *
Emergency Contact Phone Number *
Please list any persons (other than Parent/Guardian or Emergency Contact) who are authorized to pickup your child from CHAMPS programs. Children will not be dismissed to anyone not on this list without written consent from parents.
Which days will your child attend CHAMPS? (Champs is $5.00 per day) *
Required
Does your child have any allergies/medical conditions or take any medications? *
If you answered yes above, please describe. (Note allergies, medical conditions and/or name of medications) If none, type N/A *
I give permission for my child to receive CPR/First Aid by certified staff members. In the event of an emergency I understand my child will be transported to (via ambulance) and treated by the Hartford Healthcare Medical Group Emergency Room. *
I give permission for my child to be transported to CHAMPS partner locations via the WPS bus system. Locations include: Pearson, Oak St. & Batcheller School, Northwest CT YMCA, Beardsley & Memorial Library, American Mural Project, and other locations in town. (If no is selected, students will ONLY be able to participate in the CHAMPS school-based activities) *
For students attending Pearson School Only: I give permission for my child to walk home from after school programs held at Pearson School. Only students who are designated walkers and in grades 4-6 will be allowed to do this. Students are NOT permitted to walk home from any other CHAMPS Programs/Activities/Locations. If left blank, this will automatically default to NO.
Clear selection
I give permission for my child to be photographed/videotaped while at CHAMPS (school based and partner sites). These photos/videos may be used on the District/CHAMPS/AMP/BML/YMCA social media accounts, other publications such as newspapers & marketing materials. I understand that my child's name may appear with these photos. *
Please give any information that will be helpful to the CHAMPS staff caring for your child.
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