Williamsport City Parks Program 2011

YMCA Registration Form Pay $5 Weekly _______

My child(ren) will attend (circle one): Memorial Park Shaw Place Pay in Full _______

Official Use Only

Start Date: _________________

Child(ren)’s Name(s): ______________________________________________________________

Address: ________________________________________________________________________

Phone: ____________________Age(s): ______ ; _______ Birth Date(s):_____________; _____________

Parent/Guardian Name: _____________________________________________________________

Address: ________________________________________________________________________

Phone: ____________________

Emergency Contact(s) if Parent/Guardian not available:

Name: _____________________________________ Phone: _______________________
Relationship: _____________________________________

Name: _____________________________________ Phone: _______________________

Relationship: _____________________________________

Statistical Information – This information is CONFIDENTIAL and only used for general statistical and
grant funding purposes. Providing this information does not affect your eligibility for the program.

Annual Gross Household Income: Child’s Ethnicity:

______ Under $10,000 ______ $40,001 - $50,000 _________________________
______ $10,001 - $20,000 ______ $50,001 - $60,000
______ $20,001 - $30,000 ______ $60,001 - $70,000
______ $30,001 - $40,000 ______ Over $70,000

Does this family reside in subsidized housing (Section 8)? Yes No

Hold Harmless Agreement

I/We agree to indemnify and save harmless The City of Williamsport, YMCA, it’s officers, agents and
employees from and against all loss or expense (including attorney fees) by reason of liability imposed by law
upon The City of Williamsport and YMCA for damages due to bodily injury, including loss to thereof, arising
out of or in consequence of the performance of this agreement, providing such injury to persons or damage to
property is due or claimed to be due to the negligence of the above name participant, it’s officers, employees or
agents. A copy of this authorization shall be as effective as the original.

___________________________________________ ________________
Signature of Parent/ Guardian Date
Form updated 4/11/08
Medical Information
Allergies/Infections/Diseases

Hay Fever _____ Asthma _____

Bee Stings _____ Ear Infection _____
Poison Ivy _____ Hepatitis _____
Penicillin _____ HIV Positive _____
Foods _____ Animals _____
Other _____
Additional or Specific Information: ___________________________________________
________________________________________________________________________
Physician’s Name: ____________________________ Phone: _________________
Do you carry hospital/medical insurance: yes _______ no ________
Policy holder’s name: _________________________________________________
Name and Identification number: ____________________________________________

__________________________________________ _______________
Signature of Parent/Guardian Date

Field Trip and Transportation Permission Form

I hereby give permission for _________________________________________ to attend and be transported to
and from all summer parks program trips as part of the City of Williamsport and YMCA’s summer parks
program. (This includes roller-skating, swimming, and other trips associated with the program.)

_____________________________________________ _______________
Signature of Parent/Guardian Date

Authorized Pick – Up Form

Please list up to four (4) people you authorize to pick up your child from the summer parks program.
Remember to include carpool drivers, neighbors, co – workers, relatives, or emergency situations. These
individuals must be able to present (upon request) valid picture identification. Please provide phone numbers as
well.

1. __________________________________ 2. _________________________________
3. __________________________________ 4. _________________________________

___________________________________________ ________________
Signature of Parent/Guardian Date

Authorized to Walk
By signing below, I authorize my child to sign themselves in and/or out as needed, and that they are authorized
to walk to and from the program without supervision.

____________________________________________ ________________
Signature of Parent/Guardian Date

Form updated 4/11/08

Photographic Release
I hereby give consent to The City of Williamsport and the YMCA to reproduce photographs or videos of my
child for advertising and publicity purposes.

______________________________________ ________________
Signature of Parent/Guardian Date

Religious/Church Consent
Several Christian organizations have offered to assist the City in providing recreation opportunities to the youth
participating in the summer playground program. Some, but not all, activities will have a religious component
such as a Bible study, or the children may be offered the opportunity to attend Vacation Bible School. By
signing below you are giving your child permission to participate in the Christian oriented activities. If you DO
NOT wish for your child to participate in these activities, DO NOT sign this section.

___________________________________________ __________________
Signature of Parent/Guardian Date

Summer Parks Program Rules and Regulations

• All participants MUST be registered.

• Profanity is not acceptable.
• Argumentative behavior/physical altercation is not tolerated.
• No spitting, begging, snitching, or name – calling.
• Keep your hands, feet, and all other body parts/objects to yourself at all times.
• Return all items to their original place.
• Shirts and shoes must be worn at all times, and in an appropriate manner.
• Proper shoes must be worn to use playground equipment.
• Illegal drugs, tobacco, alcohol and WEAPONS OF ANY KIND are prohibited.
• All problems will be handled by the Parks and Recreation/YMCA Staff ONLY.
• Parks and Recreation/YMCA is not responsible for lost or stolen items
• Parks and Recreation/YMCA has the right to refuse entrance to any individual.
• Any person entering the program may be searched at any time.
• Severe weather(thunderstorm)-child MUST be picked up

The Parks Program discipline procedure is as follows:

Manner of discipline will be determined by the Parks Directors according to the severity of the behavior
including (but not limited to) fighting, misbehaving on field trips, profanity, stealing, or not following the
rules set up by the staff. Possible disciplinary actions include:
• Loss of activities/privileges
• Verbal warning to the child and the parent will be notified in writing.
• Parent/Staff conference
• Suspension/Termination

I will help my child to understand and abide by the rules set by the staff, and realize that some children simply do not
adjust well to a new setting.

I, the parent of _______________________ fully understand the summer parks program rules and will explain them to
my child and help to reinforce them to the best of my ability.

__________________________________ _________________
Signature of Parent/Guardian Date

Form updated 4/11/08

 LUNCH PROGRAM INFORMATION
Lunch will be served to children who are registered and attend the
program from 9am – 3pm in its entirety, unless previous arrangements
have been made with the Recreation Coordinator or Site Supervisor. Due
to the nature of our lunch program, we must have the daily attendance
called in by 9:15am. Any child that is not present by 9:15am will not
receive a lunch. In addition, there is only one lunch option each day - if
your child does not like the lunch being served, they may bring their own.

By signing below, I understand that if my child(ren) is/are not present

by 9:15am, they will not be provided with a lunch.

___________________________ ____________
Signature of Parent/Guardian Date

Special arrangements:
___________________________________________________________
_________________________________________________

Parks and Recreation/YMCA staff are responsible for registered children

in the park between the hours of 9:00am and 3:00pm ONLY. If your child
is present at the park before 9:00am or after 3:00pm, they will not be
supervised.

___________________________ ____________
Signature of Parent/Guardian Date

WHAT TO BRING?
• Water Bottle
• Towel/Swimsuit
• Sunscreen
Form updated 4/11/08
YMCA Financial Aid Application
All requested documents must be returned with this application. Failing to do so will delay processing.

Today’s Date: __________________ Date you need care to start: _____________________

Child(ren)’s name(s) needing care: __________________________________ Age: _________

__________________________________ Age: _________

__________________________________ Age: _________

Parent(s)/Guardian(s): _________________________________________ Family Size: _______

Address: _________________________________________

_________________________________________

Home Phone: _________________________________________

Employer: ________________________________________________

Work Phone: ___________________________

Monthly Income Checklist (please check and submit all that apply for EACH household member):

_____ 4 consecutive paystubs if paid weekly

_____ 2 consecutive paystubs if paid bi-weekly

_____ Benefits (Social Security, Pension, etc.)

_____ Child Support / Alimony

_____ Other sources

I hereby acknowledge that the information submitted is complete and accurate.

Parent/Guardian Signature:_____________________________________________________

Form updated 4/11/08