Hands Extended Fishing Program

Hands Extended Fishing Program Registration Form

Hands Extended Fishing Program (510) 845-3161
One form Per Child. Please Print Clearly - Incomplete or Illegible Forms Will be Returned Unprocessed.
Enrollment Form is all 3 pages plus essay. All pages must be completed with signatures.

Child's Name_________________________________ Birthday______________________
^Last ^First ^mm/dd/yyyy Address__________________________________________________________________

School__________________________________Entering Grade_______Age___________

Sex:_____Female_____Male

Does the Participant have any medical conditions or disabilities?_____Yes_____No.
If yes, please describe________________________________________________________ .
^{(E.g. ABHD, Bee Stings, Food Allergies, Asthma, taken Medication)}

Child's Doctor's Name:______________________Doctor's Phone( )________________

Medical Insurance Information__________________________________________________
^Company ^Policy# ^{Exp Date}

Child's T-Shirt size (Circle One): Youth Sizes YS YM YL Adult Sizes AS AM AL

CRITICAL CONTACTS: PARENT(S) LEGAL GUARDIAN/EMERGENCY CONTACT

Parent/Guardian #1_____________________________( )___________( )___________
^Last ^First ^{Day Phone} ^{Evening Phone}

________Yes Send me vital program information via Email. Email Address:________________

Parent/Guardian #2______________________________________________________________
^Last ^First ^{Day Phone} ^{Evening Phone}

________Yes Send me vital program information via Email. Email Address:________________

Local Emergency Contact________________________( )___________( )___________
^{Different than #1 & #2} ^Last ^First ^{Day Phone} ^{Evening Phone}

CHECK-IN/OUT OPTIONS:

_____ ON-YOUR-OWN: Provide own transportation to and from event : I will drop and pickup child.

_____ SIGN-OUT: My child should be kept at camp in the designated check-out area until an authorized person meets him/her to sign out the child. List additional authorized sign out people below.

Subsequent additions and deletions to this list must be made in writing. Print Clearly.

_______________________________ _______________________________
^Last ^First ^Last ^First

__________ Check if I want PHOTO IDENTIFICATION checked daily for the person signing out my child (must be on sign-out list).

Indicate name here if there is anyone your child should NEVER be released to:

_____________________________________________________________________________
^Last ^First

HOW DID YOU HEAR ABOUT US?

How did you hear about our programs? (circle all that apply): brochure friend/referral flyer

Other (describe)___________________________________________________________

____ I want to help Hands Extended and would like to donate $ 25_____ $ 50_____ $ 100_____

____ Other. All donations are tax deductible.

Any special diets________________________________________________________________

_____________________________________________________________________________

OFFICE USE ONLY

Signed Release Agreement on file:

Confirmation letter sent/faxed_________________ Copies made_________________
^Date

Date:_________________ Receptionist___________________________

Acceptance Letter on File:___________________________ Copies made_________________

Date:_________________ Receptionist___________________________

Invitations sent out : Date:_________________ Receptionist___________________________