Summer Playground Health/Information/Permission Form

Mail, Email, Fax or Drop Off at CER office by the Wednesday prior to your child’s first day.

Form must be in our possession for child to participate

Circle Park Attending: Buscher Park Ray Erlandson Park Pleasant View Park Wheeler Park Madison Lake
NAME / PHONE / SEX
M / F
ADDRESS
MOTHER/GUARDIAN / HOME # / CELL#
PLACE OF WORK / WORK#
FATHER/GUARDIAN / HOME # / CELL#
PLACE OF WORK / WORK#
IF NECESSARY, WHO SHOULD BE CONTACTED? / 1ST / 2ND
IF UNABLE TO REACH PERSONS ABOVE, CONTACT: (please list an alternative contact):
NAME / RELATIONSHIP / PHONE #’s
If Divorced or separated, who does the child primarily live with?

Important Information

The playground program is a supervised activity, but it should NOT be considered childcare. Since the program is primarily a neighborhood based program children may be walking or riding bikes to and from the parks and departing the program at various times throughout the afternoon.

Please indicate below your child’s normal method of transportation to and from the playground.

Walks/bikes / Dropped Off/Picked Up / Other-please explain

Please indicate below if your child may or may not leave the playground on his/her own.

My child may come and go from playground on his/her own / My child may NOT leave the park without supervision

Please list individuals whom you give your permission to pick up your child without prior notification:

Name / Address / Phone #’s

Is there anyone whom you do not wish to pick up your child under any circumstances? *Name & Explanation (if desired)

*If you have a court order prohibiting contact by a parent or anyone else, please include a copy with your paperwork

(Turn Over To Complete Other Side Please)

HEALTH

Please list any medical or special needs the Playground Staff should be aware of (i.e. Allergies, Diabetes, Adult PCA accompanying with child, Physical Limitations, Mental Disabilities, Emotional Difficulties, Wheelchair Seating, Interpreter etc.)

Child’s Shoe Size (To be used for Bowling & Ice Skating Field Trips) Youth Size Adult Size

------

Field Trip Waiver: Field trips will occur to a variety of locations throughout the summer. Transportation will be provided by properly insured school busses.

Yes, l permit my child to accompany the CER Playground Program on field trips. This permission is given with the understanding that transportation will be provided by properly insured school busses.

No, my child is not permitted to accompany the CER Playground Program on field trips. I understand all staff will accompany children on field trips and that no staff will be at the park on those days so there will be no program at the park on field trip days.

Media Release: At times, articles on the Summer Playground Program may appear in the local paper(s) in District publications, on television broadcast or video. NOTE: At no time will any personal information be used.

Yes, the Summer Playground Program has my permission to use the name, picture and anecdotes of my child.

No, the Summer Playground Program may not use my child’s name or picture.

COMMUNITY EDUCATION & RECREATION SUMMER PLAYGROUND PERMISSION FORM

The information given above is correct and complete and I give permission for my child to participate in all Community Education & Recreation Summer Playground activities and understand that transportation will be required. The Community Education & Recreation Department is not liable in case of accident and would like to inform you as a parent or guardian of this.

Date Parent/Guardian Signature or Typed Name