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City of Zephyrhills
Summer Recreation Program Registration Form
Student Name: _________________________________________________________________
(Last Name) (First Name)
Date of Birth: ____________________ Age: _____ Grade Completed: __________
Address: ______________________________________________________________________
Home Phone: _____________________ Cell Phone: _____________________
Mother: ____________________________ Father: ____________________________
Employed by: _______________________ Employed by: _______________________
Work Phone: _______________________ Work Phone: ________________________
Emergency Contacts In Case Parents Cannot Be Reached Who Will Be
Responsible To Care For Your Child
Name: __________________________________ Phone: _______________________
Name: __________________________________ Phone: _______________________
List any chronic health problems: __________________________________________________
________________________________________________
In case of injury or illness and should parents not be able to be contacted, do we (City of Zephyrhills Summer Rec Staff) have permission to make whatever arrangements are necessary to provide care and/or treatment for your child. _____ Yes _____ No
If no, please list any specific instructions for care for the child: _______________________________
_____________________________________________________________________________________________________
My child has permission to participate in all activities of Zephyrhills Summer Recreation program except: __________________. I understand my child will be transported by bus to all activities located away from the school site and I give permission for my child to do so.
_________________________________________ _______________________
Parent Signature Date