ПЛАСТ Станиця Вашінґтон - PLAST Washington, D.C. Branch
РЕЄСTРАЦІЯ / REGISTRATION 2019 - 2020 р.
Це є наш перший рік в Пласті у Вашінгтоні (This is our first year in Plast in Washington, DC) *
Required
Прізвище дитини (Child's surname): *
Your answer
Ім’я дитини (Child's name): *
Your answer
Дата народження (DOB): *
Your answer
Алергії (Allergies or Medical alerts): *
Your answer
Рівень української мови, говорить (Level of conversational Ukrainian): *
Рівень української мови, розуміє (Level of understanding of Ukrainian): *
Назва щоденної школи (Name of American School) *
Your answer
Кляса (Grade, American School) *
Your answer
Кляса (Grade, Ukrainian School)
Your answer
Домашня Адреса (Home Address) *
Your answer
Домашний телефон (Home telephone)
Your answer
Прізвище, Ім’я Матері (Mother - Last Name, First) *
Your answer
Mобільний тел. Матері (Mother Cell) *
Your answer
Е-пошта Матері (Mother E-mail) *
Your answer
Прізвище, Ім’я Батькa (Father - Last Name, First) *
Your answer
Mобільний тел. Батькa (Father Cell) *
Your answer
Е-пошта Батькa (Father E-mail) *
Your answer
Е-пошта дитини (Child's E-mail)
Your answer
Preferred contact person and method *
Your answer
Адреса батьків/опікуна, якщо є різна (Parent/Guardian address if different from above):
Your answer
Kонтакт, якщо не зможемо зв’язатися з батьками. Прошy включіть ім’я, прізвище, відносини та телефон (Emergency contact, should parents not be available. Please include name, relationship and phone #): *
Your answer
I, the parent or legal guardian of the child, give permission for my child to participate in all Plast activities. I do agree further for myself, and my successors and assigns the above-named Child/Children, his/her heirs, successors and assigns, to release and hold harmless Plast Ukrainian Scouting Organization, USA., its directors, officers, agents, employees, volunteers and members and all of them from and against any and all claims, by whomever made or presented, for damages or compensation due to any loss, damage or injury arising from or connection with any Plast activities including transportation to and from Events, excluding only claims arising solely from the gross negligence of Plast, or any of its officers or employees. I specifically represent that my Child is enrolled in a health insurance plan, which will provide coverage for any injury or illness requiring medical attention that my Child/Children may suffer while participating in Plast activities. If my health plan does not cover the full cost of care received by my Child/Children, I agree to be responsible for and to pay for the cost of such care and leave Plast harmless. In the event of a medical emergency, I authorize any licensed physician or any practitioner at a licensed medical facility to provide such medical care to my Child/Children as they may determine is appropriate. Third parties may accept and rely on a photocopy of this document as though it were an original. I also hereby authorize and consent the use and reproduction by Plast of any and all photographs of my child or family for the purpose of promoting Plast Washington Branch activities.
Підпис (Signature) [Typing your name will count as substituting for a written signature]: *
Your answer
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