Fillable Summer 2020 Registration Form Covid Fillable (City of Alameda)

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Summer 2020 Registration Form Covid Fillable (City of Alameda)

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  • 24 check-boxes
  • 80 other fields

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File type: PDF

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Alameda Recreation and Park Department
2226 Santa Clara Avenue, Alameda, CA 94501
(510) 747-PLAY • FAX (510) 523-4071
Tax ID#: 94-6000288
arpd@alamedaca.gov • www.alamedaca.gov/recreation
REGISTRATION FORM
• Full payment is due at the time of registration. Checks payable to
ARPD, American Express, Discover, MasterCard or VISA accepted.
• Withdrawals may be made by e-mail or phone with a $15 processing
fee (or otherwise stated). The remainder of the fee may either be
refunded or left as a credit on your account to be used in the future.
• Parents/Guardians, there is a late fee of $1 per minute per child for
every minute you are late
picking up your child/children from
programs/classes – payable that day.
CLASSES
AND SPORTS
ONLINE
Mail:
ARPD Main Office
2226 Santa Clara Ave
Alameda, CA 94501
(510) 747-7529
arpd@alamedaca.gov
www.alamedaca.gov/recreation
PARTICIPANT’S
BIRTHDATE M/F
GRADE
(IF ANY)
ACTIVITY TITLE CLASS # FEE
LAST NAME
TOTAL FEES DUE: $
MAIN CONTACT OR PARENT/GUARDIAN INFORMATION:
LAST NAME:
FIRST NAME:
BIRTHDATE:
ADDRESS: CITY: ZIP:
PRIMARY/CELL PHONE:
SECONDARY PHONE:
EMAIL ADDRESS:
EMERGENCY CONTACT:
RELATIONSHIP TO PARTICIPANT:
PHONE:
EMERGENCY CONTACT (OTHER THAN PARENT):
RELATIONSHIP TO PARTICIPANT:
PHONE:
PARTICIPANT’S MEDICAL ISSUES/ALLERGIES:
LIABILITY WAIVER
1. Undersigned hereby releases, waives and discharges the City of Alameda, its directors, employees, agents, volunteers and independent contractors from all liability to the
undersigned and/or his/her personal representatives, assignees, heirs, and next of kin for any loss or damage and any claim or demands accruing or resulting from injury to the
person or property or death of the undersigned or my child whether or not caused by the negligence and/or property of the City of Alameda, its directors, officers, employees,
agents, volunteers, and independent contractors.
2. Undersigned hereby assumes full responsibility for and risk of bodily injury, death or property damage, whether or not it is due to the negligence of the City of Alameda, its
directors, employees, agents, volunteers and independent contractors or otherwise while in, upon or about the premises of the City of Alameda and/or while using the premises
or facilities or equipment, including AED machines, or program transportation thereon.
CONSENT TO TREAT: I hereby give my consent for the City of Alameda staff to take me (or my child/ward) to the appropriate medical services and give appropriate medical
authorization in the event that I cannot be immediately contacted. It is understood that the cost thereof will be at my expense.
Check here if I DO NOT consent to treat and I request that medical or surgical services be withheld.
WELLNESS CHECK: I hereby confirm that my child has not had a fever of 100 degrees or above, shown signs of respiratory illness (cough, sore throat or shortness of breath), or
been in close contact with a person who has COVID-19 for at least 14 days prior to the start of the summer program. I hereby give my consent for the City of Alameda staff to take
my child’s temperature before the start of programs each day and understand that my child must stay home if my child has a fever of 100 degrees or above or exhibits signs of
respiratory illness and can return to the summer program only when symptoms improve, there is no fever for 72 hours without the use of fever-reducing medicine, and at least ten
days have passed since illness onset.
PHOTO RELEASE: I understand that photographs may be taken of me or my child during the course of said activity, and that these photographs may be used in the City of
Alameda publications, including but not limited to recreation brochures, the City’s website, and the City’s Facebook page or other City social media sites.
Undersigned has read and voluntarily signs the release and waiver of liability and indemnity agreement, and further agrees that no oral representation, statements or inducement
apart from the foregoing written agreement has been made.
SIGNATURE:______________________________________ DATE:________________ Participant Parent/Guardian
CHECK (payable to ARPD)
AMEX / Discover / VISA / MASTERCARD #: _____________________________________ CVV #_______ Exp. Date________
Name on Card________________________________________________ Signature__________________________________________
Address on Card_________________________________________________________________________________________________
By signing, I authorize the City of Alameda to charge my credit card for the activity costs listed above.
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Alameda Recreation and Park Department
2226 Santa Clara Avenue, Alameda, CA 94501 - (510) 747-7529 / FAX: (510) 523-4071
arpd@alamedaca.gov / www.alamedaca.gov/recreation - Tax ID: #94-6000288
2020 SUMMER REGISTRATION FORM – PAGE 2
WORLD OF WONDER (WOW) PROGRAM
– Monday to Friday, 8:00 a.m. to 5:00 p.m.
For Boys & Girls Who Have Completed Kindergarten-4th
Grades as of Summer 2020 – Bring Bag Lunch Daily
CHILD #1 NAME: CHILD #2 NAME:
PARENT/GUARDIAN’S NAME(S): PHONE: EMAIL ADDRESS:
PERSON(S) AUTHORIZED TO
PICK UP CHILD/CHILDREN –
List First & Last Name(s)
CHILD
SESSIONS (3 WEEKS)
COST PER
3-WEEK SESSION
WOW SITE
#1
#2
SESSION 1 – Mon-Fri, June 15 - July 3 $700 PER PERSON Godfrey (#9563) Washington (#9566)
SESSION 2 – Mon-Fri, July 6 - July 24
$700 PER PERSON
Godfrey (#9564)
Washington (#9567)
SESSION 3 – Mon-Fri, July 27 - August 14
NOTE: August 10th week will be credited back if AUSD begins
the school year early
$700 PER PERSON Godfrey (#9565) Washington (#9568)
DAY CAMP PROGRAM – ALL CAMPS HELD AT ROBERT CROWN STATE BEACH PARK, ALAMEDA
CHILD #1 NAME:
CHILD #2 NAME:
PARENT/GUARDIAN’S NAME(S):
PHONE:
EMAIL ADDRESS:
PERSON(S) AUTHORIZED TO
PICK UP CHILD/CHILDREN –
List First & Last Name(s)
CHILD
PROGRAM
DATES
(3 WEEKS)
TIMES
COST PER
3-WEEK SESSION
#1
#2
HIDDEN COVE
(Completed K & 1st Grades) June 22 - July 10 9:00 a.m. to 3:00 p.m. $625 PER PERSON
#9569
TRAILS END
(Completed 2nd-5th Grades)
July 13 - July 31
9:00 a.m. to 4:00 p.m.
$685 PER PERSON
#9570
TWEEN SUMMER ADVENTURE CAMP – McKINLEY PARK & UNDERGROUND TEEN CENTER
Completed 5th to 8th Grades
TWEEN #1 NAME: TWEEN #2 NAME:
PARENT/GUARDIAN’S NAME(S):
PHONE:
EMAIL ADDRESS:
TWEEN/TEEN #1 MAY:
SIGN IN AND OUT EACH DAY OR
ONLY LEAVE WITH THE FOLLOWING AUTHORIZED PICK
UP PERSON(S) LISTED BELOW
TWEEN/TEEN #2 MAY:
SIGN IN AND OUT EACH DAY OR
ONLY LEAVE WITH THE FOLLOWING AUTHORIZED PICK
UP PERSON(S) LISTED BELOW
PERSON(S) AUTHORIZED
TO PICK UP TWEEN(S) –
List First & Last Name(s)
TWEEN
SESSION DATES (3 WEEKS) TIMES
COST PER
3-WEEK SESSION
#1
#2
SESSION 1: June 15 - July 3
(Completed 5th-8th Grades)
8:00 a.m. to 5:00 p.m.
$700 PER PERSON
#9571
SESSION 2: July 6 - July 24 (Completed 5th-8th Grades)
8:00 a.m. to 5:00 p.m.
$700 PER PERSON
#9572
SESSION 3: July 27 - August 14 (Completed 5th-8th Grades)
NOTE: August 10th week will be credited back if AUSD begins school year early
8:00 a.m. to 5:00 p.m. $700 PER PERSON #9573
06/20/np
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Summer 2020 Registration Form Covid Fillable (City of Alameda)

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Completed 15 July 2020

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