W Program and Workshop Registration

W Program and Workshop Registration Form

Please provide participant information below, along with which programs/workshops you wish to register for. All information will be collected per registrant, with the opportunity to add additional registrants in Section 2.

Please note that all information collected in this form will be kept strictly confidential.

SECTION 1

Participant Information:

Participant Name

Address

City

Postal Code

Participant Age

Date of Birth

Contact Email

Primary Contact Phone

Program/Workshop Interest

In there is a specific program or workshop that you are interested in, please let us know below.

Parent/Guardian Information:

Custodial Parent/Guardian #1 Full Name

Primary Phone

Secondary Phone

Permission to Pick Participant Up

Yes

Custodial Parent/Guardian #2 Full Name

Primary Phone

Secondary Phone

Permission to Pick Participant Up

Yes

Add Additional Parent/Guardian Information for Participant:

Enter Additional Parent/Guardian information (Name, Work Phone, Email, Home Phone, Cell) per parent/guardian

Emergency Contact (if guardian(s) cannot be reached):

First Emergency Contact Full Name

Second Emergency Contact Full Name

First Emergency Contact Phone#

Second Emergency Contact Phone#

Transportation Needs

In some cases, YWCA Cambridge may provide families with support to transport participants to programming at The W.

If transportation is a barrier in attending program, please note that staff will provide options to support where possible

Expected Method of Transportation for participant(s):

Getting To Know Our Participants

This confidential information will be used solely to help us in getting to know your child and better understanding how we can best support them.

Please tell us below why you are interested in registering your child for our programs and/or workshops and what you hope they will gain from the experience.

All programs and workshops at The W are designed based on the interests and needs of the participants we support. What topics, skills or issues interest your child?

Health And Wellness

Mobility

Enter Additional Mobility Details Here

Asthma

Enter Additional Asthma Details Here

Dietary Restrictions

Enter Additional Dietary Details Here

Vision or Hearing

Enter Additional Vision or Hearing Details Here

Diabetes

Enter Additional Diabetes Details Here

Allergies

Enter Additional Allergies Details Here

Is there any other health/medical information our staff should know about your child?

SECTION 2 If Needed

Add A Second Participant

Second Participant Information:

Second Participant Name

Address

City

Postal Code

Participant Age

Date of Birth

Contact Email

City

Parent/Guardian Information

Custodial Parent/Guardian #1 Full Name

Primary Phone

Secondary Phone

Custodial Parent/Guardian #2 Full Name

Work Phone

Secondary Phone

Participant 2 – Add Additional Parent/Guardian Information for Participant:

Enter Additional Parent/Guardian information (Name, Work Phone, Email, Home Phone, Cell) per parent/guardian

Second Participant Emergency Contact (if parents cannot be reached):

First Emergency Contact Full Name

Second Emergency Contact Full Name

First Emergency Contact Phone#

Second Emergency Contact Phone#

Getting To Know Our Participants

This confidential information will be used solely to help us in getting to know your child and better understanding how we can best support them.

Please tell us below why you are interested in registering your child for our programs and/or workshops and what you hope they will gain from the experience.

All programs and workshops at The W are designed based on the interests and needs of the participants we support. What topics, skills or issues interest your child?

Please check words that best describe your child:
Please check ALL THAT APPLY
We want your camper to enjoy his/her time at camp. Please provide us with the following information so that we can make her/his camp experience great. Information will remain confidential.

Please indicate if your participant has any of the following:

Mobility

Enter Additional Mobility Details here

Asthma

Enter Additional Asthma Details here

Dietary

Enter Additional Dietary Details here

Vision or Hearing

Enter Additional Vision or Hearing Details here

Diabetes

Enter Additional Diabetes Details here

Allergies

Enter Additional Allergies Details here

Is there any other health/medical information our staff should know about your child?

SECTION 4

How did you hear about The W and YWCA Cambridge?

My child is a return participant

Friend/Family referral

In-School Programming

YWCA Cambridge website

Facebook

Instagram

Twitter

Other

SECTION 5

Permissions and Waivers

Photography

Your child may participate in an event or activity hosted by YWCA Cambridge where photos/video or audio recordings of participants may be taken for the purpose of representing The W in promotional materials for YWCA Cambridge. Guardians with children or youth under the age of 18 must sign this consent form in order to protect the participant’s safety and privacy.

By selecting yes below, you are consenting to:
Give consent to have photos/video/film/audio of your child(ren) taken and used in the promotional materials for YWCA Cambridge and/or The W. You understand that their image(s) may be published or used in promotional and marketing materials including, but not limited to, brochures, website graphics, social media etc. or otherwise displayed to the public or used for other educational/advertising/fundraising purposes, either in whole or in part by YWCA Cambridge. I give consent to have photos/video/film/audio of my child taken and used in the promotional materials for YWCA Cambridge and/or The W.

Photography Consent

Waiver of Claims

I consent to allow my child to participate in activities at and hosted by The W and/or YWCA Cambridge. I
release any legal recourse against The W and YWCA Cambridge and all claims resulting from personal
injury. In the case of emergency, I authorize The W staff to act on my behalf and transport my child to
the nearest medical facility by ambulance or taxi at my cost. In the case where participants will be
traveling to an activity, I am aware that the outings take place off-site from the original drop-off/pickup
site of The W unless otherwise indicated.

Waiver of Claims

I have read and agree to these terms.

W Program and Workshop Registration

SECTION 1

SECTION 2 If Needed

SECTION 4

SECTION 5

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