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Junior Program Registration

Participant’s Name *
DOB: *
Parent/Guardian Name(s) *
Phone *
Email *
Parent/Guardian Name(s) *
Phone *
Email *
Address *
City *
State *
Zip *
Age

7-1011-1314 & Up

Program

AquaticsFitness

Time

SeptemberOctoberNovember

Payment Method

Charge to RAC Member AccountContact me for payment information

*Your reservation is not complete until payment has been made. You can contact us at (916) 988-1727

Emergency Contact *
Phone *
Emergency Contact
Phone
Allergies
Medications to be administered in case of emergency
Behavioral/Emotional/Physical conditions we need to know about
Release, Waiver of Liability & Consent for Medical Treatment

In the event of illness or injury arising out of my child’s participation in RAC Summer Camp, I give consent and authorization for (1) the administration of emergency first aid care and treatment at the scene of an emergency by employee at RAC, or (2) the administration of any treatment deemed necessary by a licensed physician, and (3) the transfer to a hospital reasonably accessible.

By signing and initialing below, I agree to the following terms and conditions

all agreements must be checked

Child(ren)'s Name *
Parent/Guardian Signature *
Date *