Willamalane.org

Processed Date______________
Start Date____________________
Willamalane No-School Day
Registration Form
Child Name______________________________________________Age____Grade in Sept. ____ Birth Date______________________
Address_________________________________________________Zip_____________Home Phone_____________________________
Mother/Guardian Name___________________________________Employer__________________________Work Phone___________
Address_____________________________________Cell Phone______________________E-Mail_______________________________
Father/Guardian_________________________________________Employer__________________________Work Phone___________
Address_____________________________________Cell Phone_____________________E-Mail________________________________
How did you hear about Willamalane? A Friend Internet Search Returning Participant Flier from School Brochure
Basic Participant Information: The following questions are designed to help us understand your child’s individual needs. The child care environment is
different from both home and school and we want to set your child up for success. Please answer honestly and completely. Attach any other information that
will help us prepare for your child’s attendance. Once registered, you may receive additional information and forms to complete and bring with you on your
child’s first day.

Allergies (list all allergies, plus reaction and treatment) _______________________________________________________________
Physical limitations_____________________________________________________________________________________________
Special behavioral or developmental considerations__________________________________________________________________
Any unusual family circumstances the staff should know______________________________________________________________
Other physical or emotional issues, special needs, etc. ________________________________________________________________
Does your child take any medications? Y or N If yes, please list ______________________________________________________
Is your child currently under the care of a physician for an ongoing medical condition? ___________________________________
If so, please clarify _____________________________________________________________________________________________
Other than those listed above, who is authorized to pick up your child or be contacted in case of emergency during program hours?
(please list at least two):
Name_________________________________________________Phone__________________Relationship________________________
Name_________________________________________________Phone__________________Relationship________________________
Name_________________________________________________Phone__________________Relationship________________________

Physician_____________________________________________ Phone___________________
Dentist_______________________________________________Phone___________________
For Office Use Only
General Information Form (filled out completely)
Parent requested Accommodation Form Y or N
(Includes signature, date and DL#) Y or N
Car/Booster Seat Form (when applicable) Y or N

Received Handbook Y or N
Medication Release Y or N

Child REQUIRES Life Jacket (ages 6-11) Y or N
Court Orders Y or N
(If yes, attach a copy of the order)

Fee Waiver AFS* Other
Permission Slip (when applicable) Y or N

I _______authorize_______do not authorize staff at Willamalane Park and Recreation District to administer over-the-counter (OTC)
medications (nonprescription) to the above-named minor at the label-indicated dosage. I understand that any OTC medication administered I _______authorize_______do not authorize staff at Willamalane Park and Recreation District to administer over-the-counter (OTC)
will be recorded and communicated to me. Willamalane Park and Recreation District has a supply of the following medications: children’s medications (nonprescription) to the above named minor at the label-indicated dosage. I understand that any OTC medication administered acetaminophen (Tylenol), diphenhydramine (Benedryl) and ibuprofen (Motrin). To my knowledge, all allergies for the named participant will be recorded and communicated to me. Willamalane Park and Recreation District has a supply of the following medications: children’s acetaminophen (Tylenol), diphenhydramine (Benedryl) and ibuprofen (Motrin). To my knowledge, all allergies for the named participant are Parent/Guardian Printed Name___________________________________________Signature________________________________
Parent/Guardian Printed Name___________________________________________Signature__________________________________
Height of child____________ Weight of child____________ Date of last tetanus shot____________________________________
Height of child____________ Weight of child____________ Date of last tetanus shot______________________________________

*AFS patrons will be billed for programs registered. If you wish to discontinue enrollment, you must call our office, giving a two-
week notice. If notification is not given, or if AFS will not provide payment, you will be responsible for the entire unpaid balance. If
payment is not made and we are forced to send your account to a collection agency, your fees will be doubled to cover collection
costs. AFS patron initials __________
Caseworker Name___________________________Extension______________________________

Please Read Carefully
By registering my child for a Willamalane program, I agree that I am responsible for the payment of all program fees and costs as
set forth in the program payment schedule and all the information described in the handbook. If my account is assigned to a
collection agency, I agree to pay all collection costs, including fees to the collection agency. If my account is placed in the hands of an
attorney for collection, I agree to pay the reasonable attorney fees and collection costs, regardless of whether an action is filed, and if
an action is filed, I agree to pay Willamalane’s reasonable attorney fees at trial and on any appeal there from. The undersigned
releases Willamalane Park and Recreation District from all liability which may arise from the child’s participation in a Willamalane
program. The undersigned parent/guardian of child authorizes the district and its employees, agents and representatives to consent
to any medical, dental or surgical treatment, including first aid, urgent care, emergency care of any health treatment deemed
necessary or advisable under the circumstances, for the above-named child. The undersigned also authorizes such person to consent
to the transport of the child for health reasons. The undersigned agrees to be financially responsible for and to pay for any such
health treatment and transport. The undersigned authorizes Willamalane Park and Recreation District and its employees, agents
and representatives to share information about the above-named child with the child’s counselor or therapist, and with any
employee, agent or representative of the child’s school district.


Parent Driver’s License Number_______________________
Parent/Guardian Signature_________________________________________Date_______________

Source: http://www.willamalane.org/pdfs/kidsclub/registration-noschool.pdf