Preschool - the YMCA of Greater Cleveland

SWIMMING PERMISSION (CHECK APPROPRIATE ANSWER):
DATE FIELD TRIP DESTINATION DEPARTURE
TIME
6/12/13, 6/17/13,
6/19/13, 6/24/13,
6/26/13, 7/1/13,
7/3/13, 7/8/13,
7/10/13, 7/15/13,
7/17/13, 7/22/13,
7/24/13, 7/29/13,
8/2/13, 8/5/13,
8/7/13, 8/12/13,
8/14/13
Lakewood YMCA
16915 Detroit Ave
Lakewood, OH 44107
3 year old classroom
4 year old classroom
9am
12:30pm
APPROX.
RETURN
TIME
11:30am
3:15pm
MODE OF
TRANSPORTATION
YMCA Bus
YMCA Bus
PARENT/
GUARDIAN
INITIALS
1. MY CHILD IS A: SWIMMER _____ NON-SWIMMER _____
2. MY CHILD HAS PERMISSION TO PARTICIPATE IN WATER ACTIVITIES: YES _____ NO _____
Transportation services will be provided by (YMCA Staff check one):
x YMCA owned/operated bus  Leased bus with YMCA driver  Contracted bus services through school district
THE CENTER WILL NOT BE PROVIDING ADDITIONAL ADULTS OR STAFF MEMBERS
ABOVE THE RATIO REQUIREMENTS FOR THESE SWIMMING ACTIVITIES.
In the consideration of the opportunity for my child to be a participant in the YMCA of Greater Cleveland’s child care field
trip, I, the parent or guardian, hereby assume all risks and release and hold harmless the Association and all its members,
volunteers and employees from any claim that might arise as the result of my child’s participation in the field trip including
transportation related to the field trip. I have read the above and willingly consent to allow my child’s participation under the
above stated condition.
_________________________________________________
CHILD’S NAME
___________________
DATE OF BIRTH
_________________________________________
PARENT/GUARDIAN SIGNATURE
________________
DATE
REVISED: MAY 20, 2013
REV 6/07