Summer Program 2018

RPAL Summer Program Registration

We're excited to be back this summer at the RPAL Gym! The summer program is June 14–July 21.
Participant's Information
Child's Name *

First Name Last Name
Birth Date *

Month Day Year
Age- Child must be 8-12 to enroll in our Summer Program *
Gender *

Male Female
Grade (Fall 2022) *
School (Fall 2022) *
Number of summers Attended *
Ethnicity *
Primary Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Child Primarily Lives With: *
Health Insurance Carrier *
Plan Number *
Allergies, Chronic Illness, or Medical Conditions *
If your child has food allergies you must provide meals for your child to bring to the program to prevent exposure to food allergens. RPAL staff will not be responsible for ensuring that participants are not exposed to food allergens. Please initial. *
Behavioral Concerns *
Parent/Guardian Information
Name *

First Name Last Name
Primary Number *

Area Code Phone Number
E-mail *
Name

First Name Last Name
Primary Number

Area Code Phone Number
E-mail
Emergency Contacts

(Individuals other than parent or legal guardian who can be contacted in an emergency and/or who are authorized to pick up your child from the program. Each individual listed below must show current photo identification when picking up your child.)
Emergency Contact's Name *

First Name Last Name
Relationship *
Phone Number *

Area Code Phone Number
Emergency Contact's Name *

First Name Last Name
Relationship *
Phone Number *

Area Code Phone Number
Emergency Contact's Name

First Name Last Name
Relationship
Phone Number

Area Code Phone Number
I give my child permission to sign himself/herself out at the end of the day’s program: *

Yes No
I understand my child needs to bring a water bottle to refill daily: *

I understand
I have completed RPAL's registration packet which allows my child to participate in trip, activities, and consents to photo/video release. I understand that if my child's membership is not active, he/she will not be registered for Summer Program: *

I understand
Parent Name: *

First Name Last Name
Parent Signature: *

Clear
Should be Empty:

RPAL Summer Program Registration