IN South Fayette Summer 2014 | Page 64

Summer Playground Program
REGISTRATION FORM 2014
S(412) 221-8700TOWNSHIP [phone] FAX
OUTH FAYETTE OFFICE n
SUMMERFAYETTE TOWNSHIP TOWNSHIP
SOUTH FAYETTE
SOUTH PLAYGROUND PROGRAM

South Fayette Township N E WS

outh Fayette

SUMMER PLAYGROUND PROGRAM
REGISTRATION FORM 2014
SUMMER PLAYGROUND PROGRAM
[phone] OFFICE
REGISTRATION RORM 2014(412) 221-7798 FAX
F EGISTRATION FORM 2014

[phone] OFFICE 221-8700 OFFICE
[phone] FAX
(412)
[phone] FAX
Child’s Name:
First
Child’s Name: Last
Child’s Name:
Age/Grade: _____ / _______ Please Note – Child must be at leastFirst
5 years of age upon
Last
First
Last
start of program, in order to of age upon
Age/Grade: _____ / _______ _____ / Note – Child must Note – Child must be at least 5 years of age upon
Please _______ Please be at least 5 years participate.
Age/Grade:
Address:
start of program, in order to participate.
start of program, in order to participate.
City: _________________________ State: ______ Zip Code:________
Address:
Address:
City: _________________________ State: ______ Zip Code:________ Code:________
City: _________________________ State: ______ Zip
PARENT/GUARDIAN INFORMATION
P A RPARENTG/U A R D IN T / INFORMATION IIO N O R M A T I O N
ENT/
GUARDIAN I U A R D I A T
P A R E A N GN F O R M A N N F
Name:
Name:
Relationship to child: _______________ Relationship to child:________________
Name:
Name:
Name:
Name:
Home #:( ___ _____________________ Home #:(____)____________________
Relationship to)child: _______________ Relationship to child:________________
Relationship to child: _______________ Relationship to child:________________
Other#: (____) ____________________ Home #:(____)____________________
Home #:( ___ ) _____________________ Other #: (___ )_____________________
Home #:( ___ ) _____________________ Home #:(____)____________________
Other#: (____) ____________________ Other #: (___ )_____________________
Other#: (____) ____________________ Other #: (___ )_____________________
Email Address:
Email Address: Email Address:
EMERGENCYCONTACT
If neither parent is available in theG E N ofEY CONTACTN please O N T A C T
E M EMERGENCY Memergency, C Y C notify:
E R event C an CE RN TE C T
O G A
If neither parent isIfavailableparent is available in the event of an emergency, please notify:
neither in the event of an emergency, please notify:
Name:
Name:
Relationship to child:
Relationship to child:
Name:
Name:
Name:
Name:
Home #:( __ )__________________
Home #:( ___ child:
Relationship to child:
Relationship to)____
Relationship to child:
Relationship to child:
Other #: __ )__________________
Other #:
Home #:((____) __ ______________
Home #:( (____)____
Home #:( __ )_____________________)____
Home #:( ___)____
Other #: (____) __ ______________ ______________
Other #: (____)____
Other #: (____) __
Other #: (____)____
H E A L T H R E C O R D / A LL E R G I E S / M E D I C A L I N F O.
HEALTH H E A L T A LLEECRO RI E SA M E D I C E
H E A