Youth
Program Outing Registration
ASL Movie- Saturday, November 15, 2008
(Please print clearly)
| Name of Participant: ___________________________________ Age:_____ Date of Birth: __________________ |
| Home Address: _______________________________________________________________________________ |
| City: _______________________________ State: _________ Zip Code: _________________________________ |
| Parent(s) / Guardian(s) Name(s): __________________________________________________________________ |
| Home Phone Number: ( ) ________________________________ Voice TTY Both |
| Fax : ( ) ______________ Email: _____________________________________ Pager: ( ) _______________ |
| Name of School: ____________________________________ Teacher: __________________________________ |
| Emergency Contact (other than parent/ guardian): __________________________ Phone: ( ) _______________ |
| Physician’s Name: __________________________________ Phone: ( ) ______________________________ |
| Work Phone(s): Mom ( ) _____________________________ Dad: ( ) ______________________________ |
| Nature of Special Need: _________________________________________________________________________ |
| Medication--Type and Dosage: ___________________________________________________________________ |
| Please describe any pertinent information which may be helpful to CHS staff concerning the participant (allergies, |
| behavioral problems, fears, etc.): __________________________________________________________________ |
| ___________________________________________________________________________________________ |
| CHS carries liability insurance but not medical insurance. A participant's family policy must cover any medical costs incurred. I understand that every precaution is taken to protect the safety of each participant. I agree to emergency treatment by a physician or hospital in the event that I cannot be reached, and agree to release all personnel for liability in connection with this activity. A copy of the family's / child's medical insurance card is attached. |
 |
I, ______________________________, give permission for photograph, taken on _____________________ , to appear in Chicago Hearing Society / a Division of Anixter Center publicity materials (annual report, newsletter, brochure, flyer, slide show, TV, or any other publication); and/or to illustrate media articles; and/or to be used for exhibits, displays, and web pages. Signed: ______________________________ Witness: _____________________________ |
| Parent/ Guardian Name (print clearly): ______________________________________________________________ |
|
Parent/ Guardian’s Signature: ___________________________________________ Date: ____________________ |
** PLEASE BE ON TIME TO DROP OFF AND PICK UP YOUR CHILD!!!***
Please print this page, complete the form and send it to June Prusak
Chicago Hearing Society/ A Division of
Anixter Center -- Youth Program
2001 N. Clybourn Ave.-2nd Floor Chicago, IL 60614
(773) 248-9174 TTY (773) 248-9176 Fax
Email: jprusak@anixter.org