Y PL
LUGG
GED IN R
Registratio
on Fo
orm
Spring Brreakk
CSI Cam
mp
AGES: Kindergarten – 6th Grade
G
LOCA
ATION: North Baker Facility, 2725
5 7th Streett
TIME
E: Drop off between 7:3
30 – 8:00 AM.
A Pick up
any time beforee 6:00 PM
YM
Member $75/weekk*or
$$20/day**
*the cchild must be a meember
FFEE:
Non-Meember $115/weekk or
$30//day
PLU
UGGED IN DAYS For planning puurposes pre--registratioon is requireed.
Marcch
26
27
7
28
9
29
30
Sprin
ng Break
Stud
dent's Nam
me___________________________________________
____________
___________
___________
__________
(first)
(la
ast)
Child’s
C
Age___
______ Birth
h Date_____//_____/_____
_
 Male Female
Addrress________
___________
____________
___________
___________
___________
____________
___________
_________
City_
___________
_______ Statte______ Zip Code ____
____________
___
Phone #____
___________
_______
P-R-I-N
N-T NEATLY
Pare
ent / Legal Gu
uardian Nam
me(s):
Parent / Legal Guardian______
___________
___________
__ Home #__
___________
_____ Work / Cell#______
__________
Parent / Legal Guardian______
___________
___________
__ Home #__
___________
_____ Work / Cell#______
__________
EME
ERGENCY CO
ONTACT (other than Paren
nt/Guardian)
Name__________
___________
________ Ho
ome #______
________ W
Work #______
________ Ce
ell #________
______
Name__________
___________
________ Ho
ome #______
________ W
Work #______
________ Ce
ell #________
______
CO
ONTINU
UED ON REVERS
SE SIDE
E
Pare
ental / Legal Guardian
G
Au
uthorization of
o Release
, Parent/Legal Guardian
I,
(print name)
, give permissiion for the na
amed PLUGG
GED IN Studen
nt to do the
of,
(print name)
follow
wing at the en
nd of the day after PLUGGED IN. (check all that app ly):
____
___may be pic
cked up by the following pe
eople: list all people (relati ves, friends, parents) that your child ma
ay get a
ride/g
go with:
Name__________
___________
____ Phone #_________
__; Name___
____________
__________ Phone #___
________
Name__________
___________
____ Phone #_________
__; Name___
____________
__________ Phone #___
________
Name__________
___________
____ Phone #_________
__; Name___
____________
__________ Phone #___
________
____
___Other____
___________
____________
___________
___________
___________
____________
___________
__________
Pleasse list any spe
ecial instructions or any pe
ersons who are NOT autthorized to pick up your c
child?
____
____________
___________
___________
___________
____________
___________
___________
___________
_________
____
____________
___________
___________
___________
____________
___________
___________
___________
_________
Any changes to
o the above must
m
be sub
bmitted to the YMCA Sta
aff in writing
g and signe
ed by the Pa
arent / Legal
Guardian prior to
t your child being released. Your ch
hild will not b
be released to person(s) or allowed to go
anyw
where other than listed above
a
or sub
bmitted in wrriting.
____
____________
___________
___________
___________
____________
___________
___________
___________
_________
Parent / Legal Guardian Signatture
Date
Field
d Trip Permission
I here
eby grant perrmission for my
m child to atte
end the sched
duled field trip
ps as an activvity of Day Ca
amp.
____
____________
___________
___________
___________
____________
___________
___________
___________
_________
Parent / Legal Guardian Signatture
Date
Photto Release Agreement
A
(O
Optional)
Yes, I hereby gran
nt permission for the Baker County Fam
mily YMCA to take and pub
blish still photographs and//or publish
those
e previously ta
aken of my ch
hild.
____
____________
___________
___________
___________
____________
___________
___________
___________
_________
Parent / Legal Guardian Signatture
Date
The B
Baker County Family
F
YMCA will
w not deny pa
articipation in its
s Y program be
ecause of an in
ndividual's lackk of funds. Con
ntact the
YMCA
A/Sam-O Swim
m Center Front Desk Staff, Mo
onday through Friday, 9:00 a..m. to 5:00 p.m
m. for informatio
on regarding lim
mited, partial
scholarship applicattions which sho
ould be turned in at least two
o weeks before
e the sign-up de
eadline.
MAIL
L IN OR BRIN
NG COMPLETED FORM AND
A
FEE TO
O:
Bake
er County Fam
mily YMCA
580 B
Baker Street
OR
R
YMC
CA Fitness Ce
enter
Phon
2021 Main Street
ne
Bake
er City, OR 97
7814
(5
541)523-YMC
CA (9622)
FOR OF
FFICE USE
Amountt Paid $_____
___________
___
Date
Receipt #
For Youth
Y
De
evelopme
ent - Hea
althy Livving - Soccial Resp
ponsibilitty.