POWERS PARK 2015 REGISTRATION

and Emergency Contact Information

Parent/Guardian__________________________________________________________________
First name
Last name
Relationship to child_________________________________________________
Mailing Address_______________________________________________________________________
Town of Residency_______________________
email________________________________________________________________________________
Telephone
(Home)_____________________ (Cell) _________________________(Work) _____________________
Child(ren) Name(s) ____________________________________ DOB_____/__________/_______
_________________________________________DOB_____/__________/_______
_________________________________________DOB _____/__________/_______
_________________________________________DOB_____/__________/_______
Emergency number to call if parent/guardian cannot be reached:
1) Name___________________________________Phone__________________________
2) Name___________________________________Phone__________________________
3) Name___________________________________Phone__________________________
Each of these people has permission to pick up my child in case of an emergency ____Initial here

Please check all that apply:

2015 Summer Program (includes afternoon and evening swim pass)
Afternoon/Evening Child Open Swim Pass
Afternoon/Evening Adult Open Swim Pass
Family Rates
3 children
4 children
5 children
6 or more

$85______________
$60______________
$60______________
$230______________
$300______________
$340______________
$400______________
TOTAL $____________

Payment must be made in full at time of registration, scholarships will be reimbursed by Powers Park as soon as possible.

Swimming

Name_____________________Swim time____________________
Name_____________________Swim time____________________
Name_____________________Swim time____________________

LEVEL____________
LEVEL____________
LEVEL____________

Tennis

M/W AGES 5-8

T/Th AGES 9 and UP

FRIDAY-GAMES

Name_____________________Day ____________________ AGE____________

Name_____________________Day ____________________ AGE____________
Name_____________________Day ____________________ AGE____________
Who will be in attendance with your child during his/her swim lesson?
________________________________________________________
Who will be in attendance with your child during his/her tennis lesson?
_________________________________________________________

PRE-ORDER YOUR POWERS PARK SUMMER T-SHIRT

Gray with Powers Park logo across front $10 each
ys_____ym_____yl_____yxl_________ adult s_____ adult m_____ adult l_____ adult xl
_____ adult xxl
Womens style s______ m______ l_______ xl_______ xxl__________
Please initial if you do NOT want your childs photo to be used for promotional purposes. ______

If unable to contact a parent or designated agent, I give VIS permission to obtain medical help
for my child. I also understand that Powers Park/VIS does not provide staff to supervise
children who are in the pool area without a parent/daycare provider or babysitter. I also
understand that the swimming and tennis instructors are busy teaching lessons and/or watching
swimmers during program hours. The Powers Park staff and the Board of Directors are not
responsible for any children who are outside of the pool or tennis fences, unless they are
participating in a Powers Park sponsored or supervised event or activity. No children are
allowed inside the fence during non-program hours. Participant and participant's family or other
agents agree to indemnify and hold the Village Improvement Society, the Town of Lyndon, and
the Village of Lyndonville (including all officers, agents and employees) harmless from any loss
or liability which may result from claims of injury to persons or property from any cause arising
out of or during the use of the Powers Park facility by the participant(s).

___________________________
Parent/Guardian Printed Name

__________________________________
Parent/Guardian Signature