FRIDAY NIGHT FUN (K-5TH) KIDS NIGHT OUT (1).pdf · Child’s Name _____ Age (must be at least 5 at...
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Child’s Name______________________________________________________________________________ Age (must be at least 5 at attend) ______________ DOB ____________________________ Gender M F Address ___________________________________________________________________________________________________ City_______________________________________________________________ Zip ______________________________ School ________________________________________________________________________________________________________________________________________________________________________ Grade ____________________________ Parent/Guardian_____________________________________________________________________________________________________________________________________________________________ DOB ____________________________ Home # ________________________________________________________ Cell #_____________________________________________________________ Email _______________________________________________________________________ Emergency Contact Name _____________________________________________________________________________________ Relationship to Your Child ____________________________________________________________ Home Phone ______________________________________________________________________________ Cell Phone ________________________________________________________________________________________________________ Address ___________________________________________________________________________________________________ City_______________________________________________________________ Zip ______________________________ Medical Conditions/Allergies ______________________________________________________________________________________ Reaction _____________________________________________________________________________ Special Needs/Concerns ______________________________________________________________________________________________________________________________________________________________________________________ Waiver: My child is in good health and is capable of participating in Kids Night In. I understand the potential risks of participation and hold harmless the YMCA, staff, directors and volunteers from accidents resulting from participation. I authorize, in a medical emergency, after reasonable effort has been made to notify parents, that a YMCA representative may seek emergency assistance at the parent/guardian’s expense. I give my permission and consent to the YMCA to use any photos, videos or other media record of my child(ren) at this event for any lawful purpose, without compensation to me or on my behalf. If I choose not to allow my child(ren) to be in photos, videos or on other recorded media, it is my responsibility to inform the site director. Parent/Guardian Signature _________________________________________________________________________________________________________________________Date __________________________________________________ Fee $40 CCAP $20 $5 sibling discount available. Financial assistance is available to those who qualify. Contact your school’s site director for details. Payment: Cash Check #_________________________________________ Visa/MC/Amex/Disc # ______________________________________________________________________ Exp Date _______________________ Cardholder Name _________________________________________________________________________ Signature __________________________________________________________________________Date _______________________ Internal Use Only: Intake Name ____________________________________________________________________________________________________________________________________________Date _______________________ YMCA OF BOULDER VALLEY ymcabv.org Serving Boulder, Broomfield & Weld Counties Arapahoe Center 2800 Dagny Way • Lafayette, CO 80026 • 303-664-5455 Ed & Ruth Lehman Center 950 Lashley Street • Longmont, CO 80504 • 303-776-0370 Mapleton Center 2850 Mapleton Avenue • Boulder, CO 80301 • 303-442-2778 Friday, Nov 30 • 5:30-9:30pm Join us for our first Kids Night Out of the season! We’re taking a field trip to Chuck E. Cheese’s in Superior for skee-ball, whack-a- mole and arcade games. All YMCA after school participants, please check with your site director for transportation options. Drop off for non-Y participants is at 5:30pm at the Mapleton Y. Pick up for all participants is at the Mapleton Y between 9:15 and 9:30pm. Two slices of pizza, a drink and tokens are included. Turn form in to your site director by Nov 27. FRIDAY NIGHT FUN (K-5TH) KIDS NIGHT OUT Bear Creek 720-933-2318 [email protected] Creekside 720-933-1045 [email protected] Crestview 720-394-7829 [email protected] Eisenhower 720-292-7223 [email protected] Flatirons 303-909-2975 fl[email protected] Foothill 303-809-7391 [email protected] High Peak/BCSIS 720-394-7804 [email protected] Louisville 303-709-2477 [email protected] Superior 720-771-0674 [email protected] Whittier 720-412-6544 [email protected] Uni Hill 720-394-8807 [email protected]
Transcript of FRIDAY NIGHT FUN (K-5TH) KIDS NIGHT OUT (1).pdf · Child’s Name _____ Age (must be at least 5 at...
Child’s Name ______________________________________________________________________________ Age (must be at least 5 at attend) ______________ DOB ____________________________ Gender M F
Address ___________________________________________________________________________________________________ City _______________________________________________________________Zip ______________________________
School ________________________________________________________________________________________________________________________________________________________________________ Grade ____________________________
Parent/Guardian _____________________________________________________________________________________________________________________________________________________________ DOB ____________________________
Home # ________________________________________________________ Cell #_____________________________________________________________ Email _______________________________________________________________________
Emergency Contact Name _____________________________________________________________________________________Relationship to Your Child ____________________________________________________________
Home Phone ______________________________________________________________________________Cell Phone ________________________________________________________________________________________________________
Address ___________________________________________________________________________________________________ City _______________________________________________________________Zip ______________________________
Medical Conditions/Allergies ______________________________________________________________________________________ Reaction _____________________________________________________________________________
Special Needs/Concerns ______________________________________________________________________________________________________________________________________________________________________________________
Waiver: My child is in good health and is capable of participating in Kids Night In. I understand the potential risks of participation and hold harmless the YMCA, staff, directors and volunteers from accidents resulting from participation. I authorize, in a medical emergency, after reasonable effort has been made to notify parents, that a YMCA representative may seek emergency assistance at the parent/guardian’s expense. I give my permission and consent to the YMCA to use any photos, videos or other media record of my child(ren) at this event for any lawful purpose, without compensation to me or on my behalf. If I choose not to allow my child(ren) to be in photos, videos or on other recorded media, it is my responsibility to inform the site director.
Parent/Guardian Signature _________________________________________________________________________________________________________________________Date __________________________________________________
Fee $40 CCAP $20 $5 sibling discount available. Financial assistance is available to those who qualify. Contact your school’s site director for details.
Payment: Cash Check #_________________________________________ Visa/MC/Amex/Disc # ______________________________________________________________________ Exp Date _______________________
Cardholder Name _________________________________________________________________________ Signature __________________________________________________________________________Date _______________________
Internal Use Only: Intake Name ____________________________________________________________________________________________________________________________________________Date _______________________
YMCA OF BOULDER VALLEYymcabv.org
Serving Boulder, Broomfield & Weld Counties
Arapahoe Center 2800 Dagny Way • Lafayette, CO 80026 • 303-664-5455Ed & Ruth Lehman Center 950 Lashley Street • Longmont, CO 80504 • 303-776-0370Mapleton Center 2850 Mapleton Avenue • Boulder, CO 80301 • 303-442-2778
Friday, Nov 30 • 5:30-9:30pmJoin us for our first Kids Night Out of the season! We’re taking a field trip to Chuck E. Cheese’s in Superior for skee-ball, whack-a-mole and arcade games. All YMCA after school participants, please check with your site director for transportation options. Drop off for non-Y participants is at 5:30pm at the Mapleton Y. Pick up for all participants is at the Mapleton Y between 9:15 and 9:30pm. Two slices of pizza, a drink and tokens are included.
Turn form in to your site director by Nov 27.
FRIDAY NIGHT FUN (K-5TH)
KIDS NIGHT OUT
Bear Creek 720-933-2318 [email protected]
Creekside [email protected]
Crestview 720-394-7829 [email protected]
Eisenhower 720-292-7223 [email protected]
Flatirons 303-909-2975 [email protected]
Foothill 303-809-7391 [email protected]
High Peak/BCSIS 720-394-7804 [email protected]
Nombre del niño ______________________________________________________________________________________________________________Edad _______________Fecha de Nac _____________________ Sexo M F
Dirección ______________________________________________________________________________________________Ciudad _________________________________________________Código postal ______________________________
Escuela _______________________________________________________________________________________________________________________________________________________________________ Grado ____________________________
Padre/Guardián ___________________________________________________________________________________________________________________________________________________Fecha de Nac ____________________________
Tel Hogar ______________________________________________________ Cel #_____________________________________________________________ Email _______________________________________________________________________
Contacto de emergencia _______________________________________________________________________________________________ Relación con su hijo ____________________________________________________________
Home Phone ______________________________________________________________________________Cell Phone ________________________________________________________________________________________________________
Dirección ______________________________________________________________________________________________Ciudad _________________________________________________Código postal ______________________________
Condiciones médicas/Alergias _____________________________________________________________________________________________________Reacción ____________________________________________________________
Necesidades especiales/Preocupaciones ________________________________________________________________________________________________________________________________________________________________
¿Cómo escuchó de este programa? ________________________________________________________________________________________________________________________________________________________________________
Derogatoria: Mi hijo goza de buena salud y es capaz de participar en la Noche para adolescentes. Yo entiendo el riesgo potencial que puede resultar de esta participación y mantengo al YMCA, su personal, sus directores y sus voluntarios, libres de culpa por accidentes que pueden resultar en esta participación. Yo autorizo a que en una emergencia médica, después de un esfuerzo razonable que se haya hecho para notificar a los padres, que un representante del YMCA busque ayuda de emergencia a costo del padre o guardián. Yo doy mi permiso para que el YMCA use fotos, videos u otros medios de grabación de mis hijos en este evento con propósitos legales, sin compensación para mí o para mi beneficio. Si escojo no permitir que mis hijos estén en fotografías, videos u otros medios de grabación, es mi responsabilidad informar al director del sitio.
Firma del padre/Guardián ________________________________________________________________________________________________________________________ Fecha __________________________________________________
Cuota $40 CCAP $20 Descuento disponible de $5 por los hermanos. Hay ayuda financiera disponible para aquellos que califiquen. Contacte al director de su sitio para más detalles.
Pago: Efectivo Cheque # _____________________ Visa/MC/Amex/Disc # ____________________________________________________________________________________________Fecha Exp __________________
Nombre en la tarjeta __________________________________________________________________________Firma ________________________________________________________________________ Fecha _______________________
Internal Use Only: Intake Name ____________________________________________________________________________________________________________________________________________Date _______________________
Viernes 30 de noviembre • 5:30-9:30pm¡Acompáñenos en la primera noche de salida para niños de la temporada! Vamos a hacer una excursión a Chuck E. Cheese en Superior para jugar juegos electrónicos, skee-ball, y whack-a-mole. Para participantes del programa despues de escuela, hable con el director sobre opciones de transportación. Para los que no participen en el YMCA, deje a los niños en el YMCA Mapleton a las 5:30p. Los padres pueden recoger a sus hijos en el YMCA Mapleton de las 9:15pm a 9:30pm. Se incluyen dos pedazos de pizza, una bebida, y monedas para los juegos.
Entregue la forma de inscripción al director de su sitio antes del 27 de noviembre.
DIVERSIÓN DE VIERNES POR LA NOCHE (K-5TO)
NOCHE DE SALIDA PARA NIÑOS
Bear Creek 720-933-2318 [email protected]
Creekside [email protected]
Crestview 720-394-7829 [email protected]
Eisenhower 720-292-7223 [email protected]
Flatirons 303-909-2975 [email protected]
Foothill 303-809-7391 [email protected]
High Peak/BCSIS 720-394-7804 [email protected]
YMCA OF BOULDER VALLEYymcabv.org
Serving Boulder, Broomfield & Weld Counties
Arapahoe Center 2800 Dagny Way • Lafayette, CO 80026 • 303-664-5455Ed & Ruth Lehman Center 950 Lashley Street • Longmont, CO 80504 • 303-776-0370Mapleton Center 2850 Mapleton Avenue • Boulder, CO 80301 • 303-442-2778
