LADIES AUXILIARY VFW POST 3150

ANTI-BULLYING WORKSHOP

*All workshops are drop off/pick up events*

If a Girl or Boy Scout, Troop # ______________ 

 Level (circle one)     Brownies    Juniors   Cub Webelos 

Troop Leader OR Point Of Contact: ____________________________________ Phone Number:______________________

E-MAIL ADDRESS:_____________________________ [used to email receipt of the registration and workshop-related correspondence ONLY]

MAILING ADDRESS:__________________________________________________________

CITY:_____________________________________, STATE__________________ ZIP____________________

CHILD(REN)’S NAME(S):

Any Allergies?  yes      no  

If so, please provide us with details as to name of child and what she is allergic to.

Any special needs?       yes      no         How can we accommodate them?

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Event Name Event and Session (2nd-3rd grade) (4th-5th grade) Total Due+++

KARMA—Kids Against Ridicule, Meanness and Aggression

Saturday, October 26th, 2013

10 am to 3 pm

Session #_1__

$10 X_______ $10 X________ #of girls _____X $10 =

$_______________

CHILDREN MUST BRING A LUNCH AND A SNACK. NO FOOD WILL BE PROVIDED.

Alternative Emergency Contacts

* Primary emergency contact

* Home phone

* Cell

Secondary emergency contact

Home phone

Cell

Are all immunizations up to date? (yes or no) If no, please state reason why:

* Insurance company.

* Policy number & Group number

* Family Physician

* Phone.

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Subject to the conditions set forth below, I consent for my child to receive such medical treatment and/or surgical procedure deemed necessary in an emergency and assume liability for any medical expenses involved. Should a medical emergency arise during my child's participation I understand that reasonable efforts will be made to contact me or my designated alternate at the phone number listed. If it is believed that my child's health may be adversely affected by the delay attempting to contact me or my alternate would cause, I consent to the administration of medical treatment and/or surgical procedure deemed necessary by the medical doctor and/or medical facility identified or chosen by the workshop director and the immediate administration of life-sustaining measures deemed necessary under the circumstances. The health history and other information provided is correct as far as I know, and the person herein described has my permission to engage in all event activities except as noted.

I agree to these Emergency Authorization requirements, and I also agree that if the child, or children, I am enrolling appear ill, I will not send them to the workshop.

Initial HERE: .

PHOTOGRAPHIC RELEASE

The Ladies Auxiliary to VFW Post 3150 will take photographic images during the workshops. By initialing below you are giving us permission to use any and all images, of the person(s) you are registering, for our community activity book. We will not use personal information or names of participants with pictures.

Initial HERE: .

MOVIE VIEWING CLAUSE BELOW IS REGARDING THE MOVIE +++I understand when I attend the event that the movie is free and not included in the

fee. The showing of this movie is an educational event to encourage the girls in scouting to help those in need. I also understand that this is a private event and the viewing of the movie is offered by invitation only. I understand I will not be admitted without an invitation. All American Girl activity sheets are free.

Please sign stating you understand all the above information related to the movie . X______________________________________________________________

Date_____________

CHILDREN'S BELONGINGS

Please label ALL belongings. Personal belongings should be kept in a bag or backpack which will be stored in program area.

Ladies Auxiliary to VFW Post 3150 is not responsible for lost or stolen articles.

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FOOD FROM HOMEIt is recommended that lunches and snacks brought from home be nutritious and nonperishable and packed in a soft cooler/lunch bag with an ice pack. Please label food container with child’s name.Parents will be notified to bring in lunch in the event a child does not have one. No food containing NUTS or nut products shall be brought.

***NO FOOD IS PROVIDED AT THE EVENT***

I agree that I will provide a lunch and a snack for my child. This food shall be nut-free.

Initial HERE: .

HOW TO REGISTER

STEP ONE: Email us to hold you a spot at jodiedajc@yahoo.com

STEP TWO: Complete this form for each girl attending the event.

STEP THREE: Mail form, check, and list of names to the below address. Please note that emailing the form will hold your spot, but the fee for the event confirms your spot. If we do not receive payment within 2 weeks after reservation by fax, email or mail, you may lose your slot. We will try to accommodate everyone interested, therefore the fee reserves the spot.

Collect funds for event and make a check(s) payable to Ladies Auxiliary VFW Post 3150

Mail completed form to: (with Payment)

Ladies Auxiliary to VFW Post 31502116 North 19th StreetArlington, VA 22201Attn: Jodie LaFreniere-Dajc, Youth Activities Chair

STEP FOUR: You will receive confirmation via email of your reservation.

STEP FIVE: The children show up and have fun! We will do all the rest. This is a drop-off, pick-up event. Authorized individuals 18 years or older must sign child in and out each day. We I.D. all persons picking up children. Children will not be released to anyone not on the Pick-Up Authorization.

**ADDING CHILDREN---BEFORE OR AFTER PAYMENT ---Contact Jodie LaFreniere-Dajc at jodiedajc@yahoo.com    We have a limited capacity, but please contact us just in case there was a drop out etc. We have carefully calculated the number of seats available according to size limitations of our facility. Registration is closed when we are full.

**REDUCING THE NUMBER OF PARTICIPANTS- AFTER PAYMENTThere are NO REFUNDS for non attendees on the day of the event or after you have made payment for the event.  

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**You may ask others in the area if they wish to participate and substitute them for the numbers you originally registered. The substituted participants are responsible for reimbursing any costs.

I AGREE TO ALL THE TERMS AND CONDITIONS STATED HEREIN AND WAIVE THE LADIES AUXILIARY TO VFW POST 3150 OF ANY LIABILITY AS A RESULT OF THIS EVENT.

Parent/Guardian Signature:

Signature Date .

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PICK UP AUTHORIZATIONComplete this form and make copies for each child that is enrolled.

Child’s Name (please print):

The following people are authorized to pick up my child from the program. I understand my child will be allowed to leave with these individuals only. Photo identification will be asked at sign out. (Be sure to include yourself):

Authorized Person’s Name

Relationship to Child Contact Phone Number

Name of persons NOT allowed to pick up child (appropriate custody papers shall be attached if a parent is not allowed to pick up the child):

Parents/Guardians must sign children in and out each day. Date Time In Initials Time Out Initials

Parent/Guardian Signature:

Signature Date .

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