Six Days of Holiday Fun

Roller Skating … Planetarium

Children’s Museum … Ice Skating
Arts&Crafts … Games … Prizes
• December 20, 21, 22, 27, 28, 29

*Please provide your child with breakfast and lunch; we will only be
providing an afternoon snack.

*Drop off as early as 7:30am

*PICK UP NO LATER THAN 6:00pm

*All slips and payments must be turned in no later than, Wednesday,

December 15th , 2010 in order to secure your child’s spot.

*Slips turned in after Wednesday, December 15th , 2010 will be required to

pay a $5.00 late fee.

*Your space will not be reserved until a payment is made. There are only 40
spots available!

Fill out and return to Hyde Park Neighborhood Club With Payment
Attached

My child ____________________ will be attending Vacation Day Adventure on the

following days (please circle) December 20, 21, 22, 27, 28, 29

I agree that my participation (or that of my child or ward) in this program is at my own risk and
without assumption of responsibility of any kind by the Hyde Park Neighborhood Club, its
directors, officers, agents, and employees. I do hereby release, remise and forever discharge the
Club, its officers, directors, employees, agents, and representatives (the “Releases”) of and from
any and all claims, losses, injuries or damage to property suffered by me or my children or ward,
 while participating in, attending or traveling to or from the program or while using any facilities or
equipment as part of the program regardless of cause and regardless of any proved or claimed
acts of negligence or omission of duty on the part of the Releases, except for intentional harm or
gross negligence

Attached is my payment

$30.00 Regular Pay per day

$15.00 Action for Children (Must Be Pre-Approved) per day

Payment Amount:

Receipt #:

Date:

Enrollment Information

Child’s Name:_______________________________ Birth date:_________ Age:_____

Address:___________________________________ City/State:__________ Zip code________

Phone:__________________ School:________________ Grade:______ Gender:______

Legal Guardian #1:

Name_________________________________________________________

Address___________________________________ City/State:___________ zip code:________

Home Phone:_________________ Cell Phone: __________________ Email:_______________

Employer:_____________________________________ Work Phone:_____________________

Legal Guardian #2:

Name_________________________________________________________

Address___________________________________ City/State:___________ zip code:________

Home Phone:_________________ Cell Phone: __________________ Email:_______________

Employer:_____________________________________ Work Phone:_____________________

Emergency Contacts:

1. Name:________________________ Relationship:________________ Phone:_____________

Cell Phone: ___________________________ Work Phone: _____________________________

2. Name:________________________ Relationship:________________ Phone:_____________

Cell Phone: ___________________________ Work Phone: _____________________________

3. Name:________________________ Relationship:________________ Phone:_____________

Cell Phone: ___________________________ Work Phone: _____________________________

(Please initial each item.)

______ I hereby give permission for my child to participate in the indoor and outdoor
activities of the Program. Including those held in the Club Gym, local parks, and while on
field trips.

______ I hereby give permission for my child to be photographed and/or videotaped, and for
these pictures and/or film to be used by the HPNC.

Parents/Guardians Signature Date