7/28/2019 2013 Summer Day Camp Hand Out

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Please Complete the Appropriate Sections Below. One form per child

Childs Name_____________________________________DOB__________________Age_____ M/FAddress______________________________________________City_____________________Zip________Home Phone___________________________________________School____________________________Mothers Name__________________________________________Day Phone#_____________________Fathers Name___________________________________________Day Phone#____________________Email_____________________________________________________________________Emergency Contact____________________________________Contact Phone#_________________Please list special needs, allergies or health concerns:________________________________ *All children must have a health history form on file at Gold s Gym.

DATES/Price$130.00 Week

($5 off for 2nd Child)Or $30 Day

PARTIAL DAYPARTIAL WEEKPlease circle requested

days

FULL DAYFULL WEEK

(7:30am-5:30pm)Please make mark

FULL DAYPARTIAL WEEKPlease circle requested

days

June 10-14 M T W TH F M T W TH F

June 17-21 M T W TH F M T W TH F

June 24-28 M T W TH F M T W TH F

July 1-5 *closed July 4th

M T W TH F

M T W TH F

July 8 12 M T W TH F M T W TH F

July 15-19 M T W TH F M T W TH F

July 22-26 M T W TH F M T W TH F

July 29-Aug 2 M T W TH F M T W TH F

August 5-9 M T W TH F M T W TH F

August 12-16 M T W TH F M T W TH F

August 19-23 M T W TH F M T W TH F

August 26-30 M T W TH F M T W TH F

I, the participant, in registering at Gold s Gym of Eau Claire, understand that in attending the registered program and using thefacilities, do so at my own risk. Golds Gym of Eau Claire, and its owners, employees and agents, shall not be liable for any dam-ages whatsoever arising from any personal injury or property loss sustained by the participant and my family in or about any pro-grams on the premises of Golds Gym of Eau Claire. I acknowledge and am aware of the risks inherent in participating in the regis-tered programs that all sport programs are physical which can require considerable running, starting, stopping and physical exer-tion; and could potentially lead to limb injuries; possible permanent disability and death. Participants assume full responsibility forall injuries and damages which may occur in or about any programs on the premises and I do hereby fully and forever release,discharge, and hold harmless Golds Gym of Eau Claire, all associated facilities and its owners, employees and agents from anyand all demands, damages, rights of action, present of future resulting from or arising out of any persons participation in any pro-grams or use of its facilities. I agree to follow the rules of play and conduct set by Gold s Gym of Eau Claire. I understand thatfailure to do so may result in suspension from participation. Also, I waive all rights to any photos taken for use in any Golds Gymof Eau Claire publications. Missed dates are subject to full charge and are NOT subject to refund. I have read, understand andgive consent to the terms and conditions of this agreement.