Putnam Science Academy Skills and Drills Clinic

Players Information

Name (Last, First)

*

Street Address

*

City

*

State/Province

*

Postal/Zip Code

*

Phone Number (***) ***-****

*

Date

*

Grade

Current (Session = School Year) / Entering (Session = Summer)

*

School District Player Attended

*

Sessions Registration

*

April Vacation: April 14th-17th, 9am-2pm, Grades: 3-9, $250

Prospect Camp: June 26th & 27th, 9am-2pm. Grades: 5-8, $200

Summer 1: July 14th-18th, 9am-3pm, Grades: 3-9, $295

Summer 2: August 4th-6th, 9am-3pm, Grades: 3-9, $195

Christmas: December 29th-31st, 9am-2pm, $195

T-Shirt Order $0.00 T-Shirt Order

Shorts Order $0.00 Shorts Order

Parents/Guardian Information

Name (Last, First)

*

Relationship to Child

*

Email Address

*

Phone Number - Cell (***) ***-****

*

Phone Number - Home (***) ***-****

*

Address

*

City

*

State/Province

*

Postal/Zip Code

*

Emergency Contact/Authorized Pickup

Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.

Emergency Contact Information

Name (Last, First)

*

Address

*

City

*

State/Province

*

Primary phone Number (***) ***-****

*

Secondary phone Number (***) ***-****

Relationship to Child

*

Medical

Please fill out the following information about your players medical history

Does your child have any food, medication or environmental allergies?

*

If yes, what allergies?

Does your child's allergy/allergies require child care staff to monitor the child for symptoms, take action is a reaction occurs or to give emergency medication to your child?

*

Does your child have a special health or medical condition?

*

If yes, what condition(s)?

Does your child currently use any medication, food supplements, or medical foods (such as electrolyte solutions)?

*

If yes, what medication(s)?

Payment and Statement of Understanding

The Putnam Science Clinic/AAU Coaching Staff has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.*

This form, after being completed and signed by the parent/guardian, must be reviewed for completeness and signed by the administrator/designee prior to the child receiving care. After the child is attending the program the administrator shall have the parent/guardian review and initial the form when any changes/updates are made and at least annually. The parent/ guardian and the administrator or designee shall initial and date the form in the section below to indicate when the form was last reviewed.*

Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?

*

Electronic Signature

Date Signed *

Order Amount *

PSA Skills and Drills Clinic

PSA Skills and Drills Clinic

Players Information

Parents/Guardian Information

Emergency Contact/Authorized Pickup

Emergency Contact Information

Medical

Payment and Statement of Understanding

PSA Skills and Drills Clinic