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P.L.A.Y. Application

Please fill in the form below:

Family Information

Name of Child/Youth:

Birth Date: (mm/dd/yy)

Sex:

Parent/Guardian:

Address:

City/Town:

Postal Code:

Phone (Day):

Phone (Evening):

Email:

How many people are there in your family (living at home). Please include yourself:

How do you prefer to receive updates and information?

 

Do you want to receive emails regarding information about events that are happening in the City?

Is this child/youth presently under:

Does this child/youth have any medical concerns (psychological or physical)?

If Yes, please explain:

Is this child/youth presently enrolled in a Recreational Activity, such as music lessons, membership at the YMCA, in a sport, or involved in another activity?

If Yes, please explain:

Date activity ends:(mm/dd/yy)

 

Activity Information

Please send in applications ahead of time for seasonal activities.

Activity Requested:

Start Date: (mm/dd/yy)

Organization offering activity:

Organization Contact Name:

Phone:

Cost of Registration: ($)

Referral Agency if Referred

Organization:

Contact:

Address:

Phone:

Comments:

 

Waiver and Release of Medical Information

To be completed by Parent/Guardian:

I, , on behalf of my heirs, executors, assignors, and administrators, release the Human League Association from all claims, demands, or actions arising from my child/youth participating in the PLAY Program. I understand the Human League Association is not legally responsible for any injury, loss, or damage I or my child/youth may sustain while participating in a program sponsored by the PLAY Program. Furthermore, I understand that at some time, the PLAY Program Coordinator may need to discuss the mental and/or physical health of my child/youth with the Recreation Provider and hereby authorize the PLAY Program Coordinator to do so.

Signature of Parent/Guardian:

Date: (mm/dd/yy)

Release of Financial Information

To be completed by Parent/Guardian:

I, , authorize the above Referral Agency (specified above) to release personal financial information as required for determining the eligibility of my child/youth in the PLAY Program. I further authorize the PLAY Program to collect this information.

Signature of Parent/Guardian:

Date: (mm/dd/yy)

PLAY funds provided in part by:

     Travelers

Volunteering

Are you willing to volunteer for the PLAY Program?

If Yes, how?

 

 

 

 

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