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<br />ReGistration Fonn <br /> <br />Centerville's Laurie LaMotte Memorial Park <br />Park Play Days <br /> <br />Participant's Names & Ages <br /> <br />Address: <br /> <br />Phone: <br /> <br />Emergency Contact and Number <br /> <br />Doctor's Name and <br />Number: <br /> <br />Health or Physical Concerns: <br /> <br />June 19- July 19 ($48Ichlld) <br />July 24-August 18 ($48Ichild) <br /> <br />Total Amount Enclosed $ <br />Check Number <br />Mail Registration Fonn and Check to: YMCA-laChelle Williams, 600 Town Center, <br />Lino Lakes, MN 56014. 661-795-9622 <br />www.ymcatwincities.org. Make checks out to Chain of Lakes YMCA. <br />The YMCA has my permission to use photographs of my child for promotional purposes. Inltials_ <br />As p;nnt/guardlan of this chHd, I ag... to hold the <br />YMCA hannles8 from any and all claims. I authorize the YMCA smtI'to give my child ANISOII8bIe fll'1lt aJd and to <br />transport my chJld to a health care facility for emergency services 88 needed. I hereby acknowledge that the <br />YMCA wiD usume that either parent of the chId may pick up the child at anytime during the program unless <br />notified through court documentation. <br /> <br />Signature <br />Date <br /> <br />The YMCA welcomes all who wish to participate and annually raises funds through our Y Partners campaign to <br />help make that possible. <br />Pi.... let us know if we may serve your family In this way. <br /> <br />Chain of Lakes YMCA Summer '06 <br />