Girls Night Out Registration Form

Girls Night Out

Instructions:  Please print and complete this form.  Mail completed application to Wombmens Temple, 900 East Washington Street, Greensboro, NC 27410.  If you are unable to print this form, download it here:

Application for Girls Night Out – PDF

APPLICATION FOR GIRLS NIGHT OUT – FEBRUARY 25, 2011

HAYES-TAYLOR MEMORIAL YMCA – 8:00 P.M. – 8:00 A.M.

Please Print

APPLICANT’S  FULL NAME:

_____________________________________________________________________________

APPLICANT’S AGE: ________

NAME OF SCHOOL APPLICANT ATTENDS:

___________________________________________________________________________

NAME OF PARENT OR LEGAL GUARDIAN:

_____________________________________________________________________

Parent_______      Legal Guardian_________ If so, relationship to child_______________

APPLICANT’S STREET ADDRESS:

___________________________________________________________

CITY/STATE/ZIP:

___________________________________________________________

PHONE: (____) __________ – _____________  Home or Cell?  ________

EMAIL ADDRESS OF PARENT/GUARDIAN:____________________________________

EMAIL ADDRESS OF APPLICANT (optional)__________________________________

I give permission for my child to attend Girls Night Out on February 25, 2011 at the Hayes-Taylor Memorial YMCA, and give permission for my child to participate in all activities.  I understand that I need to provide transportation to and from the event, proper attire including swimsuit and towel (if child chooses to swim) for my child.  I understand that Hayes-Taylor YMCA, Wombmens Temple and Girls Night Out are not responsible for accidents, injuries or lost/stolen items.  I agree to pick up my child no later than 8:30 a.m. on February 26, 2011 from the Hayes-Taylor YMCA.  I understand the registration fee for Girls Night Out is $10.00 and is due at the time of the event.

_________________________________                         _________________________

Signature of Parent or Guardian                                                        Date


Parents/Guardians:  Please answer the following questions:

Does your child have food allergies?  Yes_____  No______

If yes, please list food allergies:

Can your child swim?  Yes_______  No_______

If yes, do you give your child permission to swim with the understanding that a YMCA Lifeguard will be on duty?  Yes_______  No_______

Does your child require medication of any sort that will need to be administered during Girls Night Out?
Yes________  No__________

If yes, please provide a list of medications, prescribing physician, medical condition for which they are prescribed, dosage and hour to be administered.

Rx Name   /  Prescribing Physician  /     Medical Condition/ Dosage   / At What Time?

Please provide us a contact in case of an emergency:

Name ________________________           Phone#_____________________

_______________________________        ____________________________

Signature of Parent or Guardian                            Date

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