“Shine, Show, & Dine” Breathe NH Fun Pass Car...

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Soccer Sign-ups JULY 22ND AUGUST 9TH 1ST 6TH GRADERS $45 PER PERSON Register before August 2nd and receive a $10 discount on the registration fee NO REGISTRATIONS WILL BE TAKEN AFTER AUGUST 9TH Wayne Robinson Director [email protected] Alyssa Hall Program Coordinator [email protected] 522-9977 CHECK US OUT ON THE WEB wakefieldrec.com Independence Day Celebration Come on down to the Ballpark for our Annual Independence Day Celebration & Fireworks show! Fun & games start at 6pm. SATURDAY, JUNE 29TH @ THE BALLPARK FIREWORKS START @ DUSK RAINDATE: JUNE 30 TH First Kicks Soccer A 5 week beginner soccer program for children 4yrs –Kindergarten (Age by September 1st 2019) $15 PER PLAYER PRE-REGISTRATION REQUIRED *If you are interested in coaching please contact Parks & Rec* SUNDAY NIGHTS 4:30-5:30PM STARTING SEPTEMBER 15 TH Breathe NH Fun Pass Wakefield Rec has partnered with Breathe NH & NHRPA to offer Fun Pass coupon books this year. For only $35, you get coupons worth $2,000 to more than 100 favorite New England family attractions! Many coupons admit a child 12 and under free or at a discounted rate with a paying adult, so with one visit to some attractions, you cover the cost of the Fun Pass. Offers and deals vary by attraction. The Fun Pass can be used as a road map to explore new places in New England and create family memories to last a lifetime. So may options from Story Land, Wildcat, Cranmore, Monkey Trunks, Funtown Splashtown, Lego Land, & MUCH MUCH MORE! BOOKLETS ARE $35 AND CAN BE PURCHASED AT THE PARKS & REC OFFICE Pick-up Pickle ball This is a low-impact doubles racket sport that blends tennis, badminton and ping pong. Pick-up style play for all levels and abilities. Equipment provided TUESDAYS & THURSDAYS 9AM-10:30AM @ THE BALLPARK PICKLEBALL IS FUN FOR ALL AGES! “Shine, Show, & Dine” Car Show Trophies, prizes, & giveaways! DJ, Food, & Ice cream vendors 50/50 Drawings Touch-A-Truck and other exhibits for the kids SUNDAY, SEPTEMBER 15TH 12-3PM @ THE BALLPARK 1488 Wakefield Road, Wakefield NH Dash plaques for the first 50 vintage cars and trucks (1994 & older) Fun for the whole family! Sponsors welcome FMI Contact Parks & Rec Diners, Dives, & Delicious Destinations Join us once a month as we venture to various restaurants for lunch with friends. The cost of the trip is $5 per person. The cost of lunch will be on your own. The “Rec Express” mini coach bus will leave from the Rec Office at 10:45am on the 3rd Wednesday of each month. JUNE 19TH MAINE DINER JULY 17TH WARRENS LOBSTER HOUSE AUGUST 21ST MOAT MTN. SMOKEHOUSE & BREWING CO. SPACE IS LIMITED. PRE-REGISTRATION IS REQUIRED

Transcript of “Shine, Show, & Dine” Breathe NH Fun Pass Car...

Page 1: “Shine, Show, & Dine” Breathe NH Fun Pass Car Showwakefieldnh.myrec.com/documents/summer_2019.pdfFriday, 8:30am-4:30pm for 8 weeks. (Extended Hours 7:30-5:30pm) The week consists

Soccer Sign-ups

JULY 22ND – AUGUST 9TH 1ST – 6TH GRADERS

$45 PER PERSON Register before August 2nd and receive a $10

discount on the registration fee NO REGISTRATIONS WILL BE TAKEN AFTER

AUGUST 9TH

Wayne Robinson

Director

[email protected]

Alyssa Hall

Program Coordinator

[email protected]

522-9977

CHECK US OUT

ON THE WEB

wakefieldrec.com

Independence Day

Celebration

Come on down to the Ballpark for our Annual Independence Day Celebration & Fireworks

show! Fun & games start at 6pm.

SATURDAY, JUNE 29TH @ THE BALLPARK FIREWORKS START @ DUSK

RAINDATE: JUNE 30TH

First Kicks Soccer

A 5 week beginner soccer program for children 4yrs –Kindergarten

(Age by September 1st 2019)

$15 PER PLAYER PRE-REGISTRATION REQUIRED

*If you are interested in coaching please contact Parks & Rec*

SUNDAY NIGHTS 4:30-5:30PM STARTING SEPTEMBER 15TH

Breathe NH Fun Pass

Wakefield Rec has partnered with Breathe NH & NHRPA to offer Fun Pass coupon books this year. For only $35, you get

coupons worth $2,000 to more than 100 favorite New England family attractions!

Many coupons admit a child 12 and under free or at a discounted rate with a paying

adult, so with one visit to some attractions, you cover the cost of the Fun Pass. Offers

and deals vary by attraction. The Fun Pass can be used as a road map to

explore new places in New England and create family memories to last a lifetime. So

may options from Story Land, Wildcat, Cranmore, Monkey Trunks, Funtown

Splashtown, Lego Land, & MUCH MUCH MORE!

BOOKLETS ARE $35 AND CAN BE PURCHASED

AT THE PARKS & REC OFFICE

Pick-up Pickle ball

This is a low-impact doubles racket sport that blends tennis, badminton and ping

pong. Pick-up style play for all levels and abilities. Equipment provided

TUESDAYS & THURSDAYS 9AM-10:30AM

@ THE BALLPARK PICKLEBALL IS FUN FOR ALL AGES!

“Shine, Show, & Dine”

Car Show

Trophies, prizes, & giveaways! DJ, Food, & Ice cream vendors

50/50 Drawings Touch-A-Truck and other

exhibits for the kids

SUNDAY, SEPTEMBER 15TH 12-3PM @ THE BALLPARK

1488 Wakefield Road, Wakefield NH Dash plaques for the first 50 vintage cars and

trucks (1994 & older) Fun for the whole family!

Sponsors welcome FMI Contact Parks & Rec

Diners, Dives, & Delicious

Destinations

Join us once a month as we venture to various restaurants for lunch with friends. The cost of the trip is $5 per person. The

cost of lunch will be on your own. The “Rec Express” mini coach bus will leave from the

Rec Office at 10:45am on the 3rd Wednesday of each month.

JUNE 19TH – MAINE DINER JULY 17TH – WARRENS LOBSTER HOUSE

AUGUST 21ST – MOAT MTN. SMOKEHOUSE

& BREWING CO.

SPACE IS LIMITED. PRE-REGISTRATION IS REQUIRED

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Wakefield Rec Summer 2014

After School Program

We will again be offering after school care from 3-5:30pm, Monday- Friday during the 2019/2020 school year.

The program will start on the first day of school and run until the last day.

SPACE IS LIMITED – PRE-REGISTRATION REQUIRED BY AUGUST 16TH

WAKEFIELD STUDENTS IN GRADES K-6TH Transportation will be provided from Paul School daily. Students will have time to wind down from school, play games, & work on homework. Snacks will be provided daily. More details are available

on our website or at the Rec office. We need a minimum of 12 children registered in order to host the program.

Teen Adventure Trips

THESE TRIPS ARE INTENDED FOR TEENS

ENTERING GRADES 6TH – 12TH MINIMUM OF 12 PARTICIPANTS MAXIMUM OF 20 PARTICIPANTS

July 11th: Canobie Lake Park: Canobie Lake Park is a family owned amusement park located in Salem NH. They offer a mixture of

thrill rides, water rides, games, & food. $35

PER PERSON. BUS LEAVES THE REC @ 11:30AM

AND WILL RETURN AT 7:30PM.

July 30th: OSG Paintball: Includes: Admission, rental marker, safety equipment, unlimited co2 canister, and 200 paintballs.

(Extra paintballs are available for an additional fee.) COST: $35 PER PERSON – BUS LEAVES THE

REC AT 8AM AND RETURNS AT 3PM. *PLEASE

PACK A LUNCH*

August 14th: Indoor Karting: NH1 Motorplex is an indoor karting venue, featuring

the world’s best electric karts, a lengthy quarter mile track with fast straight-a-ways and curvy tight turns, and an arcade for your

enjoyment. All riders must be 48” or taller. 56” is considered an adult rider. Each racer must

attend a short safety briefing. This will include instruction on how to operate your kart, safety

signs, what each flag means, and all track & kart rules. $50 PER PERSON. BUS LEAVES FROM

THE REC AT 11AM AND WILL RETURN AT 4PM. *PLEASE PACK A LUNCH*

SPACE IS LIMITED PRE-REGISTRATION IS REQUIRED

Summer Camp

Camp is offered to area children entering first-seventh grade. Our program runs Monday-

Friday, 8:30am-4:30pm for 8 weeks. (Extended Hours 7:30-5:30pm) The week consists of 2-3

field trips to local beaches, amusement parks, & zoo’s. The rest of the time is spent in Wakefield playing games, creating crafts, and visiting the

local beach. We have many options available for full & part-time campers, sibling discounts, week by week basis, and those who wish to

only attend trips.

SPACE IS LIMITED & FILLS UP FAST! PLEASE CONTACT PARK S & REC IF YOU ARE

INTERESTED IN REGISTERING.

Movies in the Park

Join your neighbors this summer for family movies in the park. Bring a blanket or chair and enjoy the magic of big screen movies under the

stars.

DUSK @ TURNTABLE PARK FREE ADMISSION

JULY 19TH – ALADDIN “G” AUGUST 25TH – HOOK “PG”

Movies start at dusk. Dusk changes over the

course of summer. In June dusk is approximately 8:45pm, while in August dusk is approximately 7:45pm. We will try to start the

movies as early as possible. There will be concessions available for purchase.

Safe Sitter Course

6th, 7th, & 8th graders Safe Sitter® prepares students to be safe when they’re home

alone, watching younger siblings, or babysitting. The lessons are filled with fun activities and role-playing exercises.

FRIDAY, OCTOBER 11TH (TEACHER WORKSHOP DAY)

9:30AM-2:30PM @ THE REC $45 PER PERSON

SPACE IS LIMITED TO THE FIRST 8 REGISTERED PARTICIPANTS.

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Page 3 of 8 Wakefield Rec Summer 2014

Portland Seadogs

THURSDAY, AUGUST 22ND $30 PER PERSON

Bus leaves from the Rec @ 3:45pm Ticket includes mini coach bus transportation,

reserved box seating & all you can eat buffet

SPACE IS LIMITED PRE-REGISTRATION IS REQUIRED

PARKS &

RECREATION….

THE BENEFITS ARE

ENDLESS!

Bingo @ Funspot

TUESDAY, JUNE 18TH WEDNESDAY, JULY 31ST

$5 per person Bingo Fees on your own

Bus leaves the Rec at 5:15pm

SPACE IS LIMITED PRE-REGISTRATION IS REQUIRED

Boston Red Sox

We were able to secure tickets again for this summer to the Boston Red Sox!

Coach Bus Transportation provided.

WEDNESDAY, JUNE 26TH OUTFIELD GRANDSTAND

$55 PER TICKET BUS LEAVES THE REC @ 9AM.

SPACE IS LIMITED PRE-REGISTRATION IS REQUIRED

Songo River Queen

The SONGO RIVER QUEEN II is a privately built replica of the famed Mississippi River

Paddle Wheelers. The QUEEN is 93 feet long, 23 feet wide, and tips the scales at over 100

tons, enabling it to offer an exceptionally smooth ride for even the most timid of

passengers. A food court is available on board for your convenience. A cocktail bar serving beer, wine, and liquor is also available. All

trips offer views of the Causeway, Mt. Washington, Birch Point, Long Island,

Arrowhead Point and Arrowhead Lodge, Camp Takajo, Pine Island, and Pleasant

Mountain, as well as beautiful waterfront properties ranging from modest camps to

multi-million dollar homes.

SUNDAY, SEPTEMBER 29TH $33 PER PERSON

THE BUS LEAVES THE REC AT 10:45AM & WILL RETURN AROUND 4:30PM PRE-REGISTRATION IS REQUIRED

SPACE IS LIMITED

Cog Railway

Your 3 hour - 6 mile round trip includes your round trip ticket, admission to the Mt. Washington Observatory Museum and approximately one hour

to enjoy the Summit of Mt Washington - the highest peak in the northeast. Enjoy spectacular views and take in the New England’s beautiful

vistas.

TUESDAY, JULY 9TH $50 PER PERSON

BUS LEAVES AT 9AM SPACE IS LIMITED

PRE-REGISTRATION REQUIRED

NH State Veteran Cemetery

The New Hampshire State Veterans Cemetery conveys peace through natural beauty and is a

source of pride to veterans' families and residents of New Hampshire. Enjoy a guided tour of the

beautiful grounds and heritage center. We will stop for lunch on the way home.

THURSDAY, JULY 25TH BUS LEAVES THE REC AT 9:30AM

$5 PER PERSON LUNCH IS ON YOUR OWN.

SPACE IS LIMITED PRE-REGISTRATION REQUIRED!

Portland City & Lighthouse Tour

Get on board the "Discovery" trolley! Sit back, relax and enjoy a 105-minute, fully narrated tour as our engaging and informative guides treat you to Portland's diverse history and hidden gems. The

childhood home of Henry Wadsworth Longfellow, the Victoria Mansion, and the bustling Old Port are just a few of the landmarks you'll see as we travel from city streets to rocky coast. We'll even make a 30 minute stop at Portland Head Light, Maine's oldest and most photographed lighthouse. So don't

forget your camera, and come see the best of Portland with us!

THURSDAY, AUGUST 8TH $35 PER PERSON

BUS LEAVES FROM THE REC AT 9:30AM & WILL RETURN AROUND 3:30PM. SPACE IS LIMITED. PRE-REGISTRATION IS REQUIRED

After the tour you will have time to walk around your own, grab lunch, and tour the shops.

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Wakefield Rec Summer 2014

MR. DREW & HIS ANIMALS TOO!

Mr. Drew and His Animals Too! Is a unique, educational show using rehabilitated and rescued animals. Mr. Drew brings a “hands on” experience

and family fun. Tuesday, July 30th

2pm @ Turntable Park (In the event of rain the show will be held @ Opera House)

WILDLIFE ENCOUNTERS

Around-the-World in 60 minutes! Professional Educators will lead the audience on an imaginary

safari around the world full of amazing animal adventures! Taking audiences on a global safari where we learn geography, discuss cultures, and

meet wildlife.

Monday, June 24th 2pm @ the Town Hall Opera House

JASON TARDY – EXTREME HIGH ENERGY JUGGLER

Jason’s show is a combination of many years of relentless practice and virtually no social life. How

else could he pull off standing on a yoga ball, juggling an ax, spiked mace, and toilet plunger, while reciting

the alphabet forward and backwards at the same time?

Tuesday, August 20th 2pm @ the Town Hall Opera House

Free Admission

MAGIC OF THE STEELGRAVES

Join the Rec for a dynamic magic & illusion extravaganza! Marcus & Angelique are back this

summer to showcase their magic with a variety of adorable animals, stunning magic, & good-natured

audience participation Tuesday, July 9th

2pm @ the Town Hall Opera House

BASKETBALL FAMILY

You will be amazed with never before seen basketball ball handling tricks with three, four, five,

and six basketballs. Ilze Luneau dribbles, juggles and spins basketballs on a balance board, and using other

props to music and dance. You can enjoy the show and at the same time hear a valuable message on setting goals, working hard, never giving up and

leading a balanced life while achieving your dreams and enjoying every day.

Tuesday, July 16th 2pm @ Turntable Park

(In the event of rain the show will be held @ Opera House)

HAMPSTEAD STAGE COMPANY

STORIES IN THE STARS Soar through the stars in this compilation of Greek

Myths! Travel the night sky and explore various constellations and legends about why they are in the sky. Audiences will delight in learning stories of the

wind, seasons, sun, and moon. This new play is designed specifically for the Summer Reading theme “A Universe of Stories”. We aim to inspire people to

once in a while, look up. Thursday, July 25th

2pm @ the Town Hall Opera House

MAD SCIENCE Are you ready for some kooky, crazy chemistry? Let

Mad Science impress kids with their over-the-top demonstrations! They will release a genie from a

bottle, and spew massive columns of foam with the use of a catalyst. Watch as they turn water into juice, cause combustion -with NO flame, and learn how to

tell the difference between acids and bases in a colorful chemical experiment. And, if that's not

enough, observe a gummy bear dive to its doom in an eruptive chemical reaction.

Tuesday, August 6th 2pm @ Turntable Park

(In the event of rain the show will be held @ Opera House)

WAYNE FROM MAINE

The Wayne from Maine show is a 45 minute interactive musical experience for the young and young at heart. Wayne has been performing and

recording children's music for over a decade delighting audiences with his very own brand or

"Edu-Tainment". Tuesday, August 13th

10am @ Turntable Park (In the event of rain the show will be held @ Opera House)

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Page 5 of 8 Wakefield Rec Summer 2014

Foxwoods Casino & Resort

THURSDAY, AUGUST 29TH $35 per person

Includes coach bus transportation & A Food Credit

Bus leaves Wakefield Rec @ 6am

SPACE IS LIMITED PRE-REGISTRATION IS REQUIRED

Policies

The Rec Department reserves the right to cancel any program, event, or activity due to insufficient registration or for any other reason preventing a

quality activity. No refunds, credits, or transfers will be issued after the first day of the class or program. Full refunds or credits may be granted prior to the

start date of a class or program. We are always looking for new trips, events, and activities, as well

as instructors for new and exciting classes. Feel free to share your ideas with us!

Senior Meals & Bingo

MONDAY – WEDNESDAY – THURSDAY BINGO @ 9AM ~ LUNCH @ 12 NOON

GREATER WAKEFIELD RESOURCE CENTER $3 DONATION REQUESTED

EVERYONE is welcome for the meal, for those who have not yet reached 60 the suggested donation is

$5.00. Monthly menus are posted on

www.greaterwakefieldresourcecenter.webs.com

[email protected] (603) 473-8324

Summer Discount

Ticket Program

Purchase your tickets at the Rec and SAVE! We have tickets available for purchase to Funtown

Splashtown, Water Country, & Six Flags New England. Save money and time at the gate.

FUNTOWN SPLASHTOWN - $30 At the gate you would pay $39 – you save $9!

WATER COUNTRY - $36 At the gate you would pay $44.99 – you save $8.99!

SIX FLAGS NEW ENGLAND - $40 At the gate you would pay $59.99 – you save $19.99!

Tickets are limited for each attraction.

Yoga

Yoga classes enhance your posture, coordination and mental focus by improving your flexibility, strength

and balance. Let the yoga poses and breath work help quiet the chatter of daily life and relieve stress. Leave

feeling rejuvenated.

TUESDAY’S 6 – 7PM @ THE REC

$10 PER CLASS OR $60 FOR AN 8 SESSION PUNCH CARD

DON’T FORGET YOUR YOGA MATS! Instructor: Susan Chadbourne

Cabbage Island Clambake

TUESDAY, JUNE 25TH $95 PERSON

BUS LEAVES REC @ 7AM & ROCHESTER HOME DEPOT @ 7:30AM

Join in on our annual trip to Cabbage Island! We will begin with time to browse the shops and village of

Boothbay. Then hop aboard the Bennie Alive, as we embark on a scenic tour of Boothbay Harbor as we

head to Cabbage Island in Linekin Bay. When we reach the island, a fabulous feast will be waiting at

the water’s edge. Your clambake includes New England Fish Chowder, Steamed Clams, Two Maine

Lobsters, Corn on the Cob, Onion and Potatoes, Blueberry Cake, Coffee or Iced Tea

(Chicken available by request) SIGN-UP EARLY!

THERE IS OFTEN A WAITING LIST FOR THIS TRIP.

BUS LEAVES REC @ 7AM & ROCHESTER HOME DEPOT @

7:30AM SIGN-UP EARLY! THERE IS OFTEN A WAITING LIST FOR THIS

TRIP.

Chair Yoga

Don't let the world of yoga intimidate you, come try Chair Yoga. Chair yoga is for everyone no matter what

condition you are in. You will learn breathing techniques for a healthy immune system. Yoga postures will be practiced seated on a chair and

standing using the chair for support. MONDAYS 8AM-9AM

@ UNION RESOURCE CENTER $5 PER CLASS

Instructor: Laurie Biracree

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Wakefield Rec Summer 2014

Gage Hill Conservation Land

Gage Hill Road

Rec Office 132 Meadow Street

John Garvin Municipal Playground 1 High Street

Ballpark Complex -1488 Wakefield Road Disc Golf, Skate Park, Basketball Court, Pickleball Courts, & more!

Lake Ivanhoe

14 Dearborn Road

Weeks Beach & Park (Great East) 138 North Shore Drive

Ames Park (Province Lake) 204 Bonnyman Road

Lovell Lake Town Beach

2017 Wakefield Road Sanbornville

Turntable Park & Cotton Valley Trail 132 Meadow Street

Lovell Lake Boat Launch Witchtrot Road Sanbornville

Union Meadows Wildlife Conservation Area

Marsh Road or Harmony Drive

Page 7: “Shine, Show, & Dine” Breathe NH Fun Pass Car Showwakefieldnh.myrec.com/documents/summer_2019.pdfFriday, 8:30am-4:30pm for 8 weeks. (Extended Hours 7:30-5:30pm) The week consists

Page 7 of 8 Wakefield Rec Summer 2014

Trips are open to all area children, resident & non resident. Each trip includes

transportation and admission to the various parks we attend. Children 1st grade and up are welcome on all day trips under the supervision of Recreation Staff. Pre-registration is

required on all trips along with a registration fee of $25. All day trips have a set rate of $30 per person. On each trip children should come to camp with lunch, sunscreen,

and plenty of water.

Squam Lake Science Center Tuesday, June 25th

Dover Bowl Wednesday, June 26th

Whites Lake State Beach Friday, June 28th

Gunstock Mountain

Monday, July 8th

Cowabunga’s Wednesday, July 10th

Ellacoya State Beach Friday, July 12th

York’s Wild Animal Kingdom Monday, July 15th

Fishercats Wednesday, July 17th

Wallis Sands State Beach Friday, July 19th

Get Air Trampoline Park Monday, July 22nd

Aquaboggan Wednesday, July 24th

Lake Wentworth State Beach Friday, July 26th

Maine Wildlife Park Monday, July 29th

Hilltop Fun Center

Wednesday, August 31st

Whites Lake State Beach

Friday, August 2nd

Lost River Gorge Monday, August 5th

Funspot & Kellerhaus Wednesday, August 7th

Wallis Sands State Beach Friday, August 9th

Storyland Monday, August 12th

Knockerball North Conway Wednesday, August 14th

Ellacoya State Beach Friday, August 16th

Chucksters Monday, August 19th

Funtown Splashtown Wednesday, August 21nd

Lake Wentworth State Beach Friday, August 23rd

Drop-off & Pick-up time for trip children is 8:30am & 4:30pm unless otherwise noted. Children must be signed in and out of camp by a parent or guardian unless prior

arragments have been made. A registration form is available on the backside of the list. Please circle the trips you wish to sign-up for and complete the registration form in order to

be registered. Payment for all trips is due at the beginning of each week. (Trips are subject to change & space fills up fast!)

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Wakefield Parks & Recreation MEDICAL/EMERGENCY INFORMATION

Participant’s Name: ___________________________________________________Sex: M______ F______ Shirt Size: S M L XL Birth date: __________/__________/__________ Age: ____________ Grade: _______________ Address: _________________________________________ City:______________________ State:__________ Zip__________________ Mailing Address (if different than above):________________________________________________________________________ List Two Emergency Contact Phone Numbers: (1) Parent/Guardian, First and Last Name: Home #__________________________________ _________________________________________ Cell/Work _______________________________ (2) Second Person, First and Last Names: Home#__________________________________ _________________________________________ Cell/Work# ______________________________ State relationship to child: _____________________ (parent, grandparent, neighbor, etc.)

Allergies (i.e. bee stings): yes____ no____ To What? _____________________________________________________________________________ Allergies to medications: yes____ no____ To What? _____________________________________________________________________________ Please list any physical, emotional, or cognitive concerns parks & rec staff should be aware of: _____________________________________________________________________________________________________________________________________

I understand that there are risks of physical injury inherent in participating in sports and recreation activities I understand that the town of Wakefield does not carry health or accident insurance for participants of its programs and strongly advise participants to carry adequate coverage for themselves and their family. I am aware of and have considered the risks of this

program before registering my child or children. I hereby release the Town of Wakefield, its employees, volunteers and agents from any liability of personal injury, loss or damage to personal property, which my child or myself may experience in

connection with activities sponsored by the Wakefield Parks and Recreation Department. Hereby consent to any medical procedures, including transportation to a medical facility, for my child in case I cannot be reached and my child has sustained

an injury. I also consent to the use of my Childs photo, video, etc. by the department for flyers, presentations, etc.

I understand this informed consent from and agree to its conditions on behalf of my child/self:

___________________________________________________________________________________________ _____________________________________ Parent/Guardian/Self Signature Date E-Mail Address______________________________________________________________________________________________________________________________

Circle One

Youth or Adult

For office use: (Program):______________________________________________________________ Paid: Cash or Check: # Receipt #: STAFF SIGNATURE:______________________