March 2016 PNO - RAGSDALE YMCA

CALLING ALL
SUPERHEROES!
MARCH PARENTS NIGHT OUT!
Calling all SUPERHEROES! It’s time to hero up and join us for a MARVELous time at the Y! Be sure to come as
your favorite superhero or create your own. This night will be filled with superhero quests, games, crafts and
more! Dinner will be served and participants will swim and watch a movie!
WHEN: Friday, March 18, 2016
REGISTRATIONS DEADLINE: Wednesday, March 16th
No registrations will be accepted after the deadline.
TIME: 6:30 P.M. - 10:30 P.M.
AGES: 5 - 12
MEMBERS: $20.00 per child
NONNON-MEMBERS: $25.00 per child
AFTER SCHOOL PARTICIPANTS: $15.00 per child
(After School participants who are registered for Parent’s Night Out
will transition directly to the event at 6:00pm without needing to be
picked up from after school)
COME PREPARED:
Dress for the theme and come dressed as your favorite
super hero or create a superhero costume of your own!
Blankets and pillows Are suggested for movie time!
ADDITIONAL INFORMATION:
• This event is held after YMCA hours, therefore the
YMCA doors will lock at 8:00pm.
• Drop off is between 6:30-7:00pm
• Pick-Up is between 10-10:30pm
• Early pick-up for emergencies only, please use the
walkie talkie located on the front patio of the YMCA
to reach a staff member in the case of an emergency.
For more information please contact Shawna Spencer, Family Services Director
336-882-9622 ext. 232
[email protected]
PARENTS NIGHT OUT - 2016 REGISTRATION FORM
All sections of this registration form must be completely filled out
PICK UP PASSWORD: _________________________________________________________________________
A PICK UP PASSWORD IS REQUIRED TO ENSURE THE SAFETY OF YOUR CHILD WHILE IN OUR PROGRAM. THIS PASSWORD SHOULD
BE SHARED WITH ANYONE WHO IS AUTHORIZED TO PICK YOUR CHILD UP FROM OUT PROGRAM.
PARTICIPANT INFORMATION
Child’s First Name: ___________________________________________________
Birthdate ______/______/______
Age ______
Medical or Allergy Information _____________________________________________
Child’s First Name: ___________________________________________________
Birthdate ______/______/______
Age ______
Last Name: ____________________________________________
Last Name: ____________________________________________
Medical or Allergy Information _____________________________________________
CONTACT INFORMATION
Street Address _________________________________________________________________________________________________
City _______________________________________________________________________
State _________________
Apt.# __________
Zip Code _________________
PARENT/GUARDIAN INFORMATION
Primary Parent/Guardian (Mother) (Father) (Other_________________)
First Name ____________________________________________________
Cell Phone ____________________________
Last Name ____________________________________________________
Work Phone __________________________
Other Phone __________________________
*MUST LIST AT LEAST ONE EMERGENCY CONTACT OTHER THAN PARENTS LISTED ABOVE*
Emergency Contact or Second Parent : Relation to Child: _______________________________________________________________
Name ________________________________________________________________________
Phone __________________________________________
The above named child is physically fit to participate in the Mary Perry Ragsdale Family YMCA program and
has my permission to do so. We (I) assume all risk and hazards incidental to the conducting of this program
and it’s activities, including transportation to and from the activities. We (I) do here by
release, absolve, indemnify and hold harmless the Ragsdale YMCA, it’s officers, directors, employees,
agents, supervisors appointed or approved by them and the owners and lessees of any activity site from any
and all liability, claims or demands arising out of the above named child’s participation in the Mary Perry
Ragsdale Family YMCA program.
Signature of Parent or Guardian: ___________________________________________________________________________________