KIDS CLUB APPLICATION
Please complete one form per child
Child's First Name *
Your answer
Child's Last Name *
Your answer
Parent's Name *
Your answer
GRADE *
Child's Birthdate *
MM
/
DD
/
YYYY
TEACHER
Your answer
Home Phone # *
Your answer
Second Phone #
Your answer
Third Phone #
Your answer
Family Email *
Your answer
Second Email
Your answer
List of people who can pick up child *
Your answer
Days of weeks you will be attending *
Required
Medical Issues our Staff need to know
Your answer
Waiver and Permission
I do hereby grant permission for my Son / Daughter / Legal Dependent to participate in the Winthrop Area YMCA Kids Club, I agree to adhere to the policies set forth in the Program Information document. I agree to pay the agreed upon fees on schedule. I agree to the Code of Conduct and support any decisions made by staff I agree to give permission for photographs to be taken of my child, to be used in program publicity and website.
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