ПЛАСТ Станиця Вашінґтон PLAST Washington, D.C. Branch
РЕЄСTРАЦІЯ / REGISTRATION 2018 - 2019 р.
Це є наш перший рік в Пласті у Вашінгтоні *
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Прізвище дитини/Child's surname: *
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Ім’я дитини/Child's name: *
Your answer
Дата нар./DOB: *
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Алергії/Allergies or Medical alerts: *
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Рівень української мови (говорить): *
Рівень української мови (розуміє): *
Віровизнання
Назва щоденної школи/ Name of American School *
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Кляса/Grade American School *
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Кляса/Grade Ukrainian School
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Домашня Адреса/Address *
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Дом.тел/ Home tel.
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Прізвище, Ім’я Матері/ Name Mother *
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Mобільний / Cell *
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Е-пошта / E-mail *
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Прізвище, Ім’я Батькa /Name Father: *
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Mобільний / Cell *
Your answer
Е-пошта / E-mail *
Your answer
Child's Email Address
Your answer
Preferred contact person and method *
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Адреса батьків/опікуна, якщо є різна / Parent address if different from above:
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В разі випадку кого повідомити, якщо не зможемо зв’язатися з батьками / In case of emergency, should parents not be available, please contact the following (include relationship and contact information):
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I, the parent or legal guardian of the child, give permission for my child to participate in all Plast activities. I acknowledge and am aware the participation in such activities could, in some circumstances, carry a risk of physical injury. I, my child, and our heirs release Plast and its respective directors, officers, servants, agents, volunteers and employees from all liability arising out of or in relation to my child’s participation in Plast activities, however such liability might arise. 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 Plast activities.
"Підпис/Signature" and Дата/Date *
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