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