Department of Library and Community Services
Community Services Division
Program Name: _ _________________________________________________
Participant’s Name: First:
Last:
Address:
City/State/Zip:
Home Phone:
Birth Date:
Parent/Guardian 1: Name:
Relationship:
Status: Married
Divorced
Legal Guardian
/
/
Caregiver
Address:
City/State/Zip:
Home Phone:
Cell Phone:
E-Mail:
Work Phone:
Parent/Guardian 2: Name:
Relationship:
Status: Married
Divorced
Legal Guardian
Caregiver
Address:
City/State/Zip:
Home Phone
Cell Phone:
E-Mail:
Work Phone:
EMERGENCY CONTACTS WITH PERSONS AUTHORIZED TO PICK UP PARTICIPANT (must be local)
Name:
Cell Phone:
Alternate #:
Relationship:
Name:
Cell Phone:
Alternate #:
Relationship:
Name:
Relationship:
PERSONS NOT AUTHORIZED TO PICK UP PARTICIPANT
Name:
Relationship:
INDEPENDENT DISMISSAL
Youth may be allowed to sign themselves in and out of the program, however, we require parent’s/guardian’s consent to do so.
No, my child may not
Yes, my child may sign himself/herself: in and/or out sign himself/herself in and out
Signature of parent/guardian if permission is given ==
>
MEDICAL HISTORY
Allergies: Pollen
Hay Fever
Bee Stings
Other Insect
Foods
Other allergies
Carries Bee Sting / Epinephrine Kit
List other allergies here:
List dietary restrictions here:
List current medications and purpose:
Please explain any other health conditions your child may have; e.g., ADHD:
Does your child require special accommodations? No
Yes; please explain: ________________________________________________________
Please contact the Recreation Coordinator two weeks prior to the start of the program if special accommodations are required
I have completed the “Waiver of Liability & Photo Release” on the other side of this registration form
IMPORTANT
Department of Library and Community Services
Community Services Division
Program Name: _ _________________________________________________
WAIVER OF LIABILITY & PHOTO RELEASE
In consideration of participation in a class or activity offered by the City of Sunnyvale Department of Library and Community
Services – Community Services Division, I, the undersigned and the parent/guardian of the Minor named on the other side of this document (hereinafter, “Minor”), hereby agree to allow the Minor to participate in this class or activity and agree to indemnify and hold the City of Sunnyvale harmless and hereby waive, release and discharge any and all claims for damage, for death, personal injury, bodily injury or property damage which Minor and/or I may have or which hereinafter may accrue to
Minor and/or myself against
