Kingsbury Club - Medfield

Child First Name(*)

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Child Last Name(*)

Please let us know your name.

Birthdate(*)

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PARENT or GUARDIAN

Parent/Guardian(*)

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Street Address(*)

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City(*)

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State(*)

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ZIP Code(*)

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Phone Number(*)

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Alternate Phone

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Email Address(*)

Please let us know your email address.

EMERGENCY CONTACT (if parent cannot be reached)

Emergency Contact(*)

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Emergency Phone(*)

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PAYMENT

Membership Type(*)

Member Non-member Invalid Input

Payment Type(*)

House Charge (members) Check Credit Card Invalid Input

DAILY SESSION

$55/$63 Members/Non-Members Daily Rates

ALLERGIES (List ALL known - include reaction and management of reaction)

Medication Allergies

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Food Allergies

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Other Allergies (insect sting, asthma, etc.)

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MEDICATIONS (List ALL medications taken routinely)

Does Child take medications routinely(*)

Yes No Invalid Input

Medication 1

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Dosage

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Time(s)

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Reason for taking

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Medication 2

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Dosage

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Time(s)

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Reason for taking

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List any past medical treatment (i.e. recent injuries, illness, surgery etc.):

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Please describe any activity from which the child should be exempted for health reasons

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PARENT AUTHORIZATIONS

The undersigned accepts fully that the Kingsbury Club, its shareholders, directors, officers, employees, representatives, and agents cannot be held responsible for any loss, claim, injury, damage, or liability sustained or incurred during participation on the premises of the Kingsbury Club.

The Kingsbury Club reserves the right to photograph program participants for publicity purposes, in print or electronic media.

I have read and agree to the above Parent Authorization(*)

Yes Invalid Input

Parent/Guardian signature (Parent, if under 18)(*)

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Validation

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