KIDS CLUB WELLNESS INTAKE FORM
Please provide information which will assist us to provide proper care of your children when in Kids Club.
Thank you!
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Child's Full Name -1st child *
1st Child's Age: *
1st Child's Birthdate *
MM
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DD
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YYYY
Child's Full Name -2nd child
2nd Child's Age
2nd Child's Birthdate
MM
/
DD
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YYYY
Your Full Name (Parent or Guardian) *
Your Email *
Your Cell Phone Number *
I understand that my child and I need to be members of the WRAC to attend Kids Club. *
Medical concerns and/or allergy information (please include name):
I wish my child to... *
Required
Special instructions I have for Kids Club Care Providers:
Please list people who you authorize to pick up your child from the WRAC facility. *
I, [Your Name] the natural parent/legal guardian of [Your Child's Name], authorize and consent to medical, surgical and hospital care, treatment, and procedures to be performed for my child by a licensed physician, emergency medical technician, or hospital when deemed immediately necessary or advisable by the physician to safeguard my child's health and I cannot be contacted. I waive my right of informed consent to such treatment and authorize permission to transport my child for emergency purposes in any vehicle driven or accompanied by Wenatchee Racquet & Athletic Club staff for such purpose while in his/her care. *
If you have more than 2 children which will be using Kids Club, please request another form. Please type your name and date below to serve as your signature to this Kids Club Enrollment form. Thank you. *
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