Name: Sunday Funday (Winter 2019)
SKU: 1302
Price: 250.00 USD
Availability: InStock

Child Information

Child's Name*

Gender

Age

Date of Birth*

Home Address*

Parent/Guardian 1 Name*

Parent/Guardian 1 Phone Number*

Parent/Guardian 2 Name

Parent/Guardian 2 Phone Number

Email*

Home Phone Number

How did you hear about us?

Membership*

If yes, Expiration Date*

Emergency Contact

Emergency Contact Name*

Emergency Contact Phone Number*

Relationship to Child*

Product Name

Security Entry Cards*

For non-members entry only. $5 each for the first 2 cards. $10 each card thereafter. **Non-Refundable**

Waiver text

I hereby give permission to the Kings Bay YM-YWHA, Inc. to take photographs of me and/or my child to be shown in a video, brochure, advertisement, or internet display for purposes of promoting interest in the Kings Bay YM-YWHA. I release the Kings Bay YM-YWHA, Inc. from any claims resulting from the pictures taken on, before, or after the date of this communication. I do hereby give permission for my child to participate in all activities, including off-ground activities. I authorize the Kings Bay YM-YWHA, Inc. to act as parent surrogate on my behalf. I realize that itineraries and/or programs are subject to change prior to, and during, the semester. I hereby give my permission for my child to participate in all programs, swimming, activities and trips as part of the 2018 Kings Bay YM-YWHA Spring children's programming. I understand and fully recognize that risks are involved. I hereby release the Kings Bay YM-YWHA or any of its sponsors, benefactors, or employees from any liability arising out of any injury to my child. In the event of a medical or surgical emergency, I grant permission to the physician designated by the Kings Bay YM-YWHA to hospitalize, secure proper treatment for, and order injections, anesthesia or surgery for my child. Furthermore, I understand that payment for medical services is the solely the family's responsibility.

Waiver*

I hereby give permission to the Kings Bay YM-YWHA, Inc. to take photographs of me and/or my child to be shown in a video, brochure, advertisement, or internet display for purposes of promoting interest in the Kings Bay YM-YWHA. I release the Kings Bay YM-YWHA, Inc. from any claims resulting from the pictures taken on, before, or after the date of this communication. I do hereby give permission for my child to participate in all activities, including off-ground activities. I authorize the Kings Bay YM-YWHA, Inc. to act as parent surrogate on my behalf. I realize that itineraries and/or programs are subject to change prior to, and during, the semester. I hereby give my permission for my child to participate in all programs, swimming, activities and trips as part of the 2018 Kings Bay YM-YWHA Spring children's programming. I understand and fully recognize that risks are involved. I hereby release the Kings Bay YM-YWHA or any of its sponsors, benefactors, or employees from any liability arising out of any injury to my child. In the event of a medical or surgical emergency, I grant permission to the physician designated by the Kings Bay YM-YWHA to hospitalize, secure proper treatment for, and order injections, anesthesia or surgery for my child. Furthermore, I understand that payment for medical services is the solely the family's responsibility.

I have carefully read the contract and other related information and agree to accept all terms as set forth above.

No refunds will be issued for any classes missed or cancelled. The Kings Bay Y will attempt to offer make-up class.

Signature*

Kings Bay YM-YWHA does not discriminate any person on the basis of race, color, religion, sex, gender identity or expression, sexual orientation, national origin, age, marital status, family status or any other characteristic protected by Federal and State laws. Kings Bay YM-YWHA will make reasonable accommodations in compliance with the Americans with Disabilities Act of 1990. To file a complaint of discrimination, write Office for Civil Rights, U.S. DHHS 26 Federal Plaza - Suite 3313 New York, NY 10278. (212) 264-3313; (212) 264-2355 (TDD); (212) 264-3039 FAX

The Kings Bay YM-YWHA is an equal opportunity provider and employer, and does not discriminate on any basis in accordance with the US Dept of Agriculture policy; nor based on race, color, religion, sex, gender identity or expression, sexual orientation, national origin, age, disability, marital status, family status or any other characteristic protected by Federal or State laws. The Kings Bay YM-YWHA will make reasonable accommodations in compliance with the Americans with Disabilities Act of 1990.

To file a complaint of discrimination, write to the Office for Civil Rights/U.S. DHHS/26 Federal Plaza, Ste 3313/New York, NY 10278. The telephone number is (212) 264-3313 or (212) 264-2355 (TDD); the fax number is (212) 264-3039. To file a complaint of discrimination concerned funded food programs, write to USDA, Director/Office of Civil Rights/1400 Independence Avenue S.W./Washington D.C. 20250-9410. You an also call (866) 632-9992 (voice) or (800) 877-8339 (TDD)

Related Information

Is the child verbal?*

Yes
No
Limited

Toileting?*

Yes
No
Limited

Eating*

Yes
No
Limited

Clothing?*

Yes
No
Limited

Allergies

Medication

Seizure Type

Medication

Date of Last Seizure

Does the child have any physical disabilities? (hearing, vision, ambulation)*

Precautions and Special Procedures

Please list any other previous organizations worked with:

No refunds: Deposits/memberships will not be refunded or transferred to any other program, department, or member after a contract is signed.
Medical Forms are due prior to the child’s admission into program.
The Kings Bay Y will not be responsible for damage or loss of personal property.
I give permission for my child to be photographed/videotaped, for in house promotional material.
Program Hours: Sunday 9:30 – 11:30 a.m. If the child is picked up after the scheduled time the parents will be charged an additional fee of $5.00 for every ten minutes.
We reserve the right to suspend or expel any child who does not comply with our behavior code.

Terms of Enrollment

I agree to the Terms of Enrollment*

I agree to the Terms of Enrollment

Parent Signature*

Date*

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Kings Bay Y