NAME: _________________________________________________      AGE:__________________

ADDRESS: _________________________________________________________________________

POSTAL CODE: _________________     PHONE: _______________________________

BIRTH DATE : __________________     MEDICARE NO. ________________________

                        Day Month Year

PARENTS/GUARDIANS NAMES: (Mother) ______________________________

                                                     (Father) ________________________________

PLACES OF EMPLOYMENT: (Mother) ____________________________________

IN CASE OF EMERGENCY, CONTACT: __________________________________

PHONE: __________________________________

SCHOOL ATTENDING: _________________LAST GRADE COMPLETED _____

FAMILY DOCTOR: _____________________________________________________

IF YOUR CHILD HAS ANY MEDICAL PROBLEMS, PLEASE DESCRIBE BELOW, I.E. ON SPECIAL MEDICATION, ETC.

SIGNATURE OF PARENT/LEGAL GUARDIAN:________________________________________         

DATE: ____________________________

PLEASE CHECK TIMES:

Regular- 8:30 a.m. – 4:30 p.m. ____ Early/Late- 7:00 a.m. – 5:30 p.m. _____

PLEASE CHECK NUMBER OF WEEKS:

1. June 28^th _____ 3. July 12 ^th _____ 5. July 26^th _____ 7. Aug. 9^th _____

2. July 5^th    _____ 4.July 19^th   _____ 6. Aug. 2^nd _____ 8. Aug. 16^th _____

WAIVER OF LIABILITY

In consideration of this application to the River Valley Community Center Foundation Inc., Summer Day Camp Program (June 28^th to August 20^th , 2010),

I, _________________________________ the parent/legal guardian of ___________________________

our heirs, executors, administrators, successors and assigns waive and release any and all rights and claims for damages we have or may have against the River Valley Community Center Foundation Inc., volunteers, directors, agents, or their representatives, successors and assigns for any and all injuries, accidents, mishaps or illnesses which may directly or indirectly result from any participation in the Programs offered by the said Community Center, and the activities associated with those programs as determined at the sole discretion of the River Valley Community Center.

I, the undersigned, the parent/legal guardian, have read this waiver and understand the terms and I acknowledge and agree to the terms stated therein.

___________________________ __________________________________________

Date Signature of Parent/Legal Guardian