The Attica Summer Park Program Registration Form 2018
The Attica Park Program is excited for another great summer to benefit the children of Attica! The Attica Park Program is an eight week program that is FREE to children that have finished kindergarten (going into 1st grade) through 6th grade (going into 7th grade). This years program runs from June 4th-July 27th 2018 from 8:00am-12:00pm.

We have a lot of fun jam packed into the program! Like summers in the past, we will be partnering with the Warren County Park Program to provide fun and educational programming for the kids. We will partake in field trips and interact with the children of the Warren County Park Program.

Come join us for our kickoff day on June 4th. A few examples of the fun things we will be doing this summer include: swimming at the Attica City Pool, attending movies at the Attica Devon Theater, visiting the Attica Public Library, bringing fun programs to the park, and many more amazing activities! We hope to see you there.

This year the Attica Park Program will escort children that wish to attend the free lunch program at the Attica Elementary School. Children will be accompanied by a park program counselor when walking to the school. However, once the children have been walked into the school, the Attica Park Program is no longer responsible for them. Arrangements will need to be made for the children once they have finished lunch.

Be sure to "like" The Attica Park Program on Facebook for updates and to keep up with all of the interesting things we will be doing this summer.

** Please fill out the form completely. If there are any questions feel free to contact the director Karley Gayler at kgayler@sycamores.indstate.edu or 765-585-9935 **

** Please complete a new form for each additional child attending the program. **

Child's Name *
Your answer
Child's Date of Birth *
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Child's Grade in School Next Year *
Child's T-Shirt Size *
Child's Home Address *
Your answer
Name of Parent/Guardian *
Your answer
Cell Phone Number *
Your answer
Work Phone Number *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Relation to Child *
Your answer
Emergency Contact Phone Number *
Your answer
Does the child have a condition we should be aware of? *
Your answer
Does the child have swimming restrictions? *
Your answer
Does the child require any special attention, medication, or routines that need to be taken into consideration at any time during our day? *
Your answer
Will your child be picked up from Ravine Park after the program? *
Will your child be attending the free lunch program and do you give permission for your child to be walked over by counselors? *
List the names AND phone numbers of the people who have permission to pick your child up from the program. *
Your answer
Do you authorize the park program director to obtain emergency treatment for your child in case of an emergency when either parent/guardian nor emergency contacts is available? *
Is there any additional information you would like the Attica Park Program directors to know?
Your answer
Please type your name as your binding signature for the registration form. *
Your answer
Date *
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