Kersey Recreation registration form

Document Sample
Kersey Recreation registration form Powered By Docstoc
					                                                                                                          Swimming Lesson Registration
                                                                                                                    Form
                                                                                                   All sessions are 10 lessons (Monday– Friday)

                                                                                              Session I            June 15-June 26
  All swimming lessons are located at the Evans Municipal Swimming                                                 Registration: May 18– June 10
  Pool, 3315 15th Ave. The Kersey Recreation Department provides
        transportation to and from the pool for an additional fee.                            Session II           July 20- July 31
                                                                                                                   Registration: May 18– July 15
  Parents and/or other siblings are NOT allowed to swim in either the
baby pool or the regular pool during swimming lessons and all of City of                      Cost: $35     ($40 for Non Kersey Residents)
                      Evans aquatics rules apply.                                                           $10 transportation fee if Kersey Rec provides transportation
                                                                                                            Transportation limited to the first 14 registrants
                                                                                                      WE HAVE UNITED WAY SCHOLARSHIPS


     Participant Name                            Birthday                  Age                    Grade                                      Sex


     Mailing Address                           City                        State                  Zip                            Home Phone


     Parent/Guardian                          Day Phone                               Cell                                   Email

 Please CIRCLE the LEVEL and SESSION. (Read the back for class descriptions)

 3-5 yr old (11:55 am-12:25 pm)
                Guppies                             Sea Horse                      Tadpole

 6 yr old (12:25 pm-1:05 pm)
                Minnow       Sea Otter                          Dolphin             Stingray                 Piranha                       Shark

 Session:
        Session I                   Session II
 I need Kersey Recreation transportation to and from the Evans Municipal Pool for an additional $10 fee.                                       YES               NO


 I _______________________ understand that any activity offered by the Kersey Recreation Department, may have an element of hazard or inherent
 danger, and I take full responsibility for my child’s actions and physical condition. I expressly understand and agree that neither the School District, the
 Town of Kersey, a municipal corporation, nor any of the officers, agents, volunteers, assistants or employees shall be held r esponsible or made subject to
 any claim seeking to assess damages or liability for, or arising from personal injury or property damage to myself or other persons on whose behalf this
 form is now signed as a result of actual or proposed participation in the above named program/s. I hereby agree to INDEMNIFY AND HOLD HARMLESS
 THE SCHOOL DISTRICT, THE TOWN OF KERSEY, THEIR OFFICERS, AGENTS VOLUNTEERS, ASSISTANT’S OR EMPLOYEES ON ACCOUNT OF
 ANY SUCH CLAIMS.

 In the event that my son or daughter is injured in any Kersey Recreation program or if a parent or guardian cannot be reached in an emergency
 situation, I give my permission for the attending physician at the site or at the hospital to treat my child.



 Emergency contact                     Relationship            Day Phone               Cell                Other


 Secondary Emergency contact           Relationship            Day Phone               Cell                Other



 Family Physician                                             Phone Number

 I BEING THE PARENT OR GUARDIAN OF THE ABOVE NAMED PARTICIPANT HAVE READ THE ABOVE INFORMATION. I STATE
 THAT TO THE BEST OF MY KNOWLEDGE THE ABOVE INFORMATION IS CORRECT.

 X
 Parent Signature                                                                              Date
 Office Use Only:    Date Received: ____________ Received By:________ Amount: ____________ Receipt #: _________________ Check:__________
                                   Swim Class Descriptions
                          American Red Cross Learn To Swim Program
Preschool Aquatic Program (3-5 Year Olds) (11:55 a.m. – 12:25 p.m.)
Guppies
Prerequisite:             3-5 Years Old
Skills/ Highlights:       Will cover water adjustment, water entry and exit, blowing bubbles, front and back float with help, kicks,
                          safety rules and more.
Seahorse
Prerequisite:             3-5 Years Old
                          Guppy Skills
Skills/ Highlights:       Will Cover front and back float/ glide, rhythmic breathing and blowing bubbles, turning over in water without
                          support, beginner stroke work, safety skills and more.
Tadpole
Prerequisite:             3-5 Years Old
                          Seahorse skills
Skills/ Highlights:        Will cover front and back crawl, bobbing/ bouncing, review safety rules, introduction of treading water,
                          increase endurance and more.

Youth Learn To Swim Program (6 Years and older) (12:25 p.m. – 1:05 p.m.)
Minnow (Level I)
Prerequisite:             6 Years and Older
Skills/ Highlights:       Will cover water adjustment and submerging water, water entry and exit, breath control skills, kicks on front
                          and back, front/back float, alternating arm actions for individual strokes and more.
Sea Otters (level II)
Prerequisite:             6 Years and Older, Minnow Skills
Skills/ Highlights:       Will cover orientation to deep water, submerging and retrieving object, fining on back, unsupported floats,
                          combining front and back stroke components and more.
Dolphin (Level III)
Prerequisite:             6 Years and Older, Sea Otter Skills
Skills/ Highlights:       Will cover jumping into deep water, gliding on front and back with push off, front crawl with breathing to
                          side, back crawl, elementary backstroke, beginning turns and more.
Stingray (Level IV)
Prerequisite:             6 Years and Older, Sea Otters Skills
Skills/ Highlights:       Will cover back/ side stroke, turns at walls, elementary backstroke and more.
Piranha (Level V)
Prerequisite:             6 Years and Older, Stingray Skills
Skills/ Highlights:       Will cover alternate breathing, refine previously learned strokes, and introduce butterfly stroke and more.
Shark (Level VI)
Prerequisite:             6 Years and Older
Skills/ Highlights:       Will cover completing 25 yards of side/ breast stroke, 10 yards butterfly, 100 yards front/ back crawl, turns
                          and more.


                                     General Information
                        How to Register                                                              Locations
          Please register in person Monday–Friday 8:00 am to 4:30 pm at             Kersey Recreation/Library
 Kersey Town Hall during registration dates. Registration deadlines are                     Phone: 970-352-8688
 listed in the program guide. Payments can be made by check, credit                         Fax: 970-353-2197
 card, or cash. Participants must live within the Town of Kersey city                       E-mail: recreation@ci.Kersey.co.us
                                                                                            413 1st Street
 limits to receive the Kersey rate. If registrations are not received on                    P.O. Box 657
 deadline date a late fee will be applied. Sorry no phone registration will                 Kersey, CO 80644
 be taken.                                                                          Kersey Town Hall
 Registration forms available at Kersey Library and Kersey Town Hall.                       Phone: 970-353-1681
 United Way Scholarships are available for eligible participants.                           Fax: 970-353-2197
                                                                                            332 3rd Street
 Check out our website: www.townofkersey.com                                                P.O. Box 657
                                                                                            Kersey, CO 80644

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:35
posted:6/23/2009
language:English
pages:2