Coes Pond Swim Lessons- Registration-English Version

Child's Name*

First Middle Last

Date of Birth*

Gender*

School Name*

Grade Entering in the Fall*

Parent/Guardian Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

Work Phone

Prefer Session Timeslot:*

Pick one (time of session will be confirmed by Aquatics Director)

9:30 AM-10:00 AM

10:00 AM-10:30 AM

10:30 AM-11:00 AM

11:00 AM-11:30 AM

Emergency Contact and Medical Info

Emergency Medical Release*

Please check box to agree

In case of an emergency, I understand every effort will be made to contact me. In the event that we cannot be reached, I hereby give permission to the physician listed on the form to hospitalize, secure proper treatment and to order anesthesia or surgery for my child.

Physician Information*

Physician's Name

Hospital Affiliation

Physician Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Physician Phone*

Medical Information*

Medical Insurance Provider

Policy and/or Group Number

Medical Conditions (Please check all that apply)*

Medical Release*

I authorize the YWCA, as agent for the undersigned, to consent with respect to said minor, to an x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to rendered under general or special supervision of, any physician or surgeon licensed under the provisions of the MA Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of the physician or at the hospital. I understand that the YWCA is not responsible for costs incurred for medical care.

Demographic Information

Please choose the appropriate selection for your family:

Household Income*

Under $17,000

$17,000 - $49,999

$50,000 - $99,999

$100,00 and more

Race of Child*

American Indian/Alaskan Native

Asian

Black

Native Hawaiian/Pacific Islander

Hispanic/Latino/a/x

Multi Racial

White

Other Race

Unknown/Undisclosed

Ethnicity of Child*

What language do you primarily speak at home?*

Chose one:

Source of Income:*

Housing Status*

Homeless

Own

Rent

Shelter

Other

Unknown/Undisclosed

Total Number Living in Household:*

Type of School (Child)*

Worcester Public Schools

Other Public School

Private/Parochial School

Homeschool

Unknown/Undisclosed