109 South Street Johnstown, PA 15901 (814) 535-8202 2015 Summer Activities Registration/Health Form     Please fill out both sides completely. Fill out an application for each child. Be sure to sign and date this application before returning it to New Day. Activities’ registration is on a first-come, first-serve basis. Name _________________________________ Nickname_________ Gender: M/F____ Current Age _____ Birth date ___________ Current Grade ______ Name of School ____________________________________ Child Address _____________________________________ City _________________ Zip _____________ Parent/Guardian’s Name(s) (please print) _______________________________________________________ Primary Phone #_________________________ Secondary Phone #_____________________ If parent or guardian is not available in an emergency, please notify: Name __________________________________Relationship_____________Phone_____________ Name __________________________________Relationship_____________Phone_____________ Check the activities in which your child will participate: o Monday Clubs 10:00am – 3:30pm at New Day o L.I.F.E. Group – one scheduled day per week. (Must come to Monday Clubs to participate) If you are signing up more than one child for LIFE Groups, would you like them to be scheduled on the same day (if we can help it). YES NO Would you like them to be in the same group? YES NO o Middle/High School Youth Group o Basketball Skills WE WILL CONTACT YOU REGARDING A START DATE.  IMPORTANT: Please turn over and fill out and sign the back. . . NEW DAY HEALTH FORM Insurance Company Name ____________________________________________________________ Policy Holder Name ____________________________________ Eff./Exp. Date_________________ Insurance Group # __________ Child’s S.S. # Other Insurance # _______ ________________________________________ Family Physician’s Name Family Physician’s Phone # Date of last physical exam_____________ Date of last Tetanus/DPT Booster _______________ List all medications your child takes on a regular basis (None will be kept by child during our programs) Medicine Dose Time(s) Reason for Taking By mouth or injection 1. ___ 2. ___ 3. ___ Does your child have asthma or any allergies*? Please explain. _______________________________ _____ ___ ____________________________________________________________________________ *If your child has the potential for allergic reactions that could require the use of an Epipen, it must be sent with them. Comment or special instructions for current health conditions: ______ ____ _______________ ____ _______________ ____ Is your child restricted from any activities? If yes, please explain. _____________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Are there any other concerns about your child that we should know? __________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________ This application and health history is correct to my knowledge. By signing below, I give my permission for the named child to attend and participate in all New Day, Inc. on and off-site activities. I expressly covenant and agree not to sue New Day, Inc, their staff, board members, or anyone associated with their activities, on or off-site facilities, (or their representatives) for any injuries or damage of any kind that may occur as a result of participating in New Day activities. I realize that New Day, Inc. reserves the right to use pictures and/or video taken for promotional purposes. I trust New Day’s discretion and will not take any legal action against New Day, Inc. or their personnel due to usage of such pictures. In case of medical illness or injury, I hereby give permission to New Day to obtain proper medical care for the person named on this application. I authorize New Day to give basic first aid care, medicine, or treatment. IN CASE OF A MEDICAL EMERGENCY or in the event that the named participant (or staff) on this Health Card needs medical care beyond New Day and off-site facilities, I understand that every effort will be made to reach the parent, guardian, relative, or friend listed. If no one can be reached, I hereby give my permission to the attending physician to treat, hospitalize, and to order injections, anesthesia, or surgery as necessary for the person named on this health card. I agree to be financially responsible for any and all treatment of my child. Signature of Parent/Guardian Date