Vacation Program

Participant's Name*

First NameLast Name

YesNo

Participant's Gender*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Participant's School*

Participant's Grade*

Parent/Guardian A Name*

First NameLast Name

Parent/Guardian A Cell Phone*

Please enter a valid phone number.

Parent/Guardian A Work Phone

Please enter a valid phone number.

Parent/Guardian A Home Phone

Please enter a valid phone number.

Parent/Guardian A Email*

example@example.com

Parent/Guardian B Name

First NameLast Name

Parent/Guardian B Cell Phone

Please enter a valid phone number.

Parent/Guardian B Work Phone

Please enter a valid phone number.

Parent/Guardian B Home Phone

Please enter a valid phone number.

Parent/Guardian B Email

example@example.com

Emergency Contact Name*

First NameLast Name

Relationship*

Day Phone*

Please enter a valid phone number.

Doctor's Name*

Doctor's Phone Number*

Please enter a valid phone number.

Please list any allergies or medical needs*

Person A*

First NameLast Name

Relationship to Person A*

Person B

First NameLast Name

Relationship to Person B

Time: 9:00am – 5:00pm
Fee: Member: $95/day or Non-Member: $110/day

Before Care: M-F starting at 8am ($10 fee)
After Care: M-Th until 6:00pm & Fridays until 5:45pm ($10 fee)

Tuesday, 3/31 - Board & Brush Field TripFriday, 4/3 - Dave & Buster's

YesNo

Tuesday, 3/31 (Before Care)Tuesday, 3/31 (After Care)Friday, 4/3 (Before Care)Friday, 4/3 (After Care)

My child, listed above, has my permission to participate in the JCC MetroWest Grade School Vacation program activities. I understand that these programs include field trips off the premises.My child, has parental permission to use the JCC Gymnasium and Pool as well as go walking in and around the building.If for any reason the registration for a particular program must be canceled, the center must be advised in writing, before the event, otherwise no refund will be given. No refund or adjustment will be given for absences.In order for a staff member to administer medication to any child, a medical permission form must be received with the medication.I understand that in case of emergency and I am unable to be contacted, I give permission to the JCC MetroWest to authorize any emergency action necessary to ensure the safety of my child.Participation in any JCC MetroWest activity and use of any recreational facilities involves risk of accidental injury despite all safety precautions. Having been informed of the activities to be conducted by the JCC MetroWest I/we, as an individual or guardian of the participants named herein, assume all risks and hazards incidental to the activities, and release from responsibility independent contractors, volunteers and all employees for any illness or injury to me or my children or family members occurring during his/her/our participation in any activities or use of any facilities at or conducted by the JCC MetroWest.

Vacation Program

EMERGENCY CONTACT INFOMATION