2018 Douglas County Summer Fun & Meals Program Registration (Free Breakfast 9-930; Fun Activity 930-1030; Free Lunch 1030-11am)
We have two program sites available to the children in and around Douglas County, IL. One site is located in Tuscola and the other in Arcola. Both sites offer free bus transportation to and from daily through the generosity of Gould Bus Service. Please answer ALL questions below prior to submitting. Thank you!
Email address *
Full Name of Parent or Legal Guardian *
Your answer
What is the full name of your child? (Only one child should be listed for each registration form.) *
Your answer
Emergency phone number is: *
Your answer
How old is the child being registered? (All children are welcome but all children must be 6 yrs of age or older in order to attend the program without a parent/guardian.) *
Did your child attend our Summer Fun & Meals Program in Tuscola or Arcola last year? *
Select ONLY ONE program site for your child to attend: (Select the Arcola site for all addresses South, West, or Southwest of Tuscola **** Select Tuscola for all addresses North, East, or Southeast of Tuscola. Bus service is available to all in and around Douglas County, IL.) *
What day(s) of the week do you expect your child to attend the program? *
Required
What day(s) does your child need free bus service to and from the program site you selected? *
Required
What is the home address for the parent/legal guardian completing this registration? *
Your answer
What is the address where your child will need to be picked up and/or dropped off by the bus?
Your answer
Will your child be picked up or dropped off at any address other than the two listed above? If yes, you must list the address below, as well as what day(s) of the week your child needs picked up or dropped off to the address you are adding below.
Your answer
RELEASE OF LIABILITY AND HOLD HARMLESS AGREEMENT: By completing and submitting this electronic registration, I attest that I am the parent or legal guardian for the child I am registering. I am submitting this electronic registration with the full understanding that my child will receive free breakfast and lunch daily at no cost to me, for all the days I selected above. I understand this registration is good for June and July 2018 in which the program is open and able to safely provide this free summer program. (Please note: ALL SITES CLOSED 7/4/18). I am checking the Yes box below and then typing my name as my electronic signature to confirm my full understanding and agreement to hold harmless, the Douglas County Health Dept, it's employees and/or all persons associated with the Summer Fun & Meals Program in both Tuscola and/or Arcola - whether paid employee or volunteer. I fully agree to hold harmless the Tuscola United Methodist Church, Arcola School, School District and Gould Bus Service and in checking the YES box below, I fully understand and agree to hold all associated with the program harmless for any accident, injury or illness that my child may incur while at any location or while participating in a field trip as part of the Summer Fun & Meals Program. I understand as parent or guardian that I am responsible for overseeing my child's dietary restrictions and will monitor the menu on the Douglas County Summer Fun & Meals Facebook Page and will make other meal arrangements whenever necessary. I understand that while every effort will be made to serve breakfast and lunch every weekday throughout June and July - I am responsible for checking and following the Facebook page during inclement weather and permit the program coordinators to contact me by any available means including email, call, or text in case of an emergency closure, illness, or injury. I understand and agree and type my name below as my signature and agreement~ *
Required
I type my name below as my signature and agreement to hold all mentioned above harmless. *
Your answer
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