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<br />REGISTRATION FORM: <br /> <br />Participants Name(s)and Age(s): <br /> <br />Address: <br />Phone: <br />Doctor's Name and Number: <br />Health or Physical Concerns: <br />Please check all programs for which you are registering. <br />Centerville Park Play Days Ages: 4-7 July 11 th - Aug 3rd <br />CentervilleParkPlayDays Ages: 8-12 July 12th-Aug4th <br />Golden Lake Park Play Days: Ages: 4-12 July 5th - Aug 3rd <br />Sports Sampler @ Golden Lake Ages: 12-15 July 11th - August 4th <br />Centerville Day Camp: <br />"" Weeks of Camp: Wk 1$100.00_ Wk 2 $125.00_ Wk 3 $125.00 _ Wk 4 $125.00 _ Wk 5 $125.00 _ Wk 6 $125.00_ <br />(7/05-7/08) (7/11-7/15) (7/18-7/22) (7/25-7/29) (8/01-8/05) (8/08-8/12) <br />Extended hours needed AM(6:30-9:00)_P.M(4:00-6:00)_ Both(6:30-9:00/4:00-6:00)_ <br />Bussing (to be arranged) needed tolfrom Golden Lake Elementary: am_pm _ both_ Paul Revere Courts _ am _ pm_ both_ <br />Total Amount Enclosed $ <br />Check Number <br /> <br />Emergency Contacts: <br /> <br />M!W <br />T/TH <br />M-Th <br />TueslThurs <br /> <br />Cost: $40!child <br />Cost: $40/child <br />Cost: $60/child <br />Cost: $30/child <br /> <br />Mail Registration Form and Check to: Chain of Lakes YMCA <br />c/o Northwest YMCA <br />3760 Lexington Ave N. <br />Shoreview, MN 55126 <br />651-792-9622 <br /> <br />www.ymcatwincities.org <br />The YMCA has my permission to use photographs of my child for promotional purposes. Initials _ As parent/guardian of this child, I agree to hold the YMCA <br />harmless from any and all claims. I authorize the YMCA staff to give my child reasonable first aid and to transport my child to a health care facility for emergency <br />services as needed. I hereby acknowledge that the YMCA will assume that either parent of the child may pick up the child at anytime during the program unless <br />notified through court documentation. Signature Date <br />The YMCA welcomes all who wish to participate and annually raises funds through our Y Partners campaign to help make that possible. <br />Please let us know if we may serve your family in this way. <br /> <br />\~ <br /> <br />YMCA <br />We build strong kids, <br />strong families, strong communities. <br />