2. Free Summer Meals, Learning, Fitness and Fun for Ages 6-12!!*

   Located at Archie Anderson Park, 28th & Alabama. Monday through Friday, June 20 - August 19 ~ 11:45 am - 3:15 pm

   *Participants MUST live in the Highlands neighborhood to attend activities/field trips!  (Beech St. to Industrial & Washington Way to Oregon Way).

   -FREE lunch and snack to all 18 and under (Lunch: 12-12:15pm, Snack: 3-3:15pm)

   -FREE activities, games, nature and outdoor recreation fun for ages 6-12

   -FREE field trips to Lake Sacajawea on Fridays

   *This project is partially funded by the City of Longview Community Development Block Grant (CDBG) Program under a grant from the U.S. Department of Housing and Urban Development, and with support from Longview School District Nutrition Services.

4. PARTICIPANT INFORMATION:
6. First Name:*
7. Last Name:*
9. Age:*
10. Gender:*
11. Date of Birth:*
13. Home Address:*
15. Parent/Guardian Name:*
16. Phone Number:*
18. Email Address:*
20. Race/Ethnicity (Check One):*

    1. White
    2. Black/African American
    3. Asian
    4. Amer. Indian/Alaskan Native
    5. Hawaiian/Other Pacific Islander
    6. Asian & White

    1. Black/African American & White
    2. Amer. Indian/Alaskan Native & White
    3. Amer. Indian/Alaska Native & Black/African American
    4. Multi-Racial
    5. Other
22. Participant receives free or reduced lunch during the school year:*

    1. Yes
    2. No
24. What do you hope your child will get out of participating in Super Summers at Archie Anderson Park?*
26. EMERGENCY CONTACT INFORMATION: ( Who to contact if parent/guardian cannot be reached)
28. Name:*
29. Relationship to Participant:*
30. Permission to pick up participant:*

    1. Yes
    2. No
32. Primary Phone Number:*
33. Secondary Phone Number:
35. TRANSPORTATION:
37. Participant has permission to walk home from the program. *

    1. I agree
    2. I do not agree

    *I understand that Longview Recreation is not responsible for the participant once they have left the program area.

39. I will be be picking up my student from program or someone from the approved list below*

    1. I agree

    • Please list all people (not yourself or anyone listed as an emergency contact) who may pick up your student from program.
    • IDENTIFICATION REQUIRED!  Please carry your ID every day in case of a staff sub.
41. Name:
42. Phone Number:
43. Relationship to Student:
45. Name:
46. Phone Number:
47. Relationship to Student:
49. Name:
50. Phone Number:
51. Relationship to Student:
53. *Please note that if your child does not have permission to walk home and no one has come to pick up your student immediately after program ends, we will call the names listed above to pick up your student, unless prior arrangements have been made. If no one is available within 1 hour of program ending, we will need to call authorities.
55. I give my student permission to take the Longview School District bus for field trips to Lake Sacajawea on the following Fridays; June 23, 30, July 17, 14, 21, 28, and August 4, 11, and 18.*

    1. I agree
    2. I do not agree
57. MEDICAL INFORMATION:
59. Family Physician:*
60. Phone Number:*
62. Describe any medical or physical condition, medication information, or allergies that could interfere with the participant's safety in these activities:

64. *Be advised, there cannot be any medication at program (not in backpacks), including inhalers, and staff cannot administer any medication to student.

66. POLICIES AND PROCEDURES:

    *Agreement is required for participation in the program.

68. I will notify the department two weeks in advance if the above participant has a disability needing special arrangements, assistance, or any condition that would limit the participant in this activity.*

    1. I agree
70. I consent for Recreation Staff to use their own judgment in securing medical aid and ambulance service in case the parents/guardians cannot be reached. A staff member may apply First Aid treatment until a doctor or medical service can be contacted.*

    1. I agree
72. I understand the City of Longview does not provide medical or accident insurance and is not responsible for personal items lost or stolen.*

    1. I agree
74. I agree to allow photographs taken during City programs to be published without limitation for non-commercial purposes.*

    1. I agree
76. ASSUMPTION OF RISK, WAIVER, & RELEASE:

    I am fully aware of the fact that there are special dangers and risks inherent in this activity, including, but not limited to, the risk of serious physical injury, death or other harmful consequences that may arise or result directly or indirectly to me from my participation in this activity. Being fully informed as to these risks and in consideration of my being allowed to participate in City sponsored activities, I hereby assume all risk of injury, damage, liability and harm to myself arising from such activities. I also hereby individually and on behalf of my heirs, executors and assigns, release and hold harmless the City of Longview, their officials, employees and agents and waive any right of recovery that I might have to bring a claim or a lawsuit against them for any personal injury, death or other consequences occurring to me arising out of my voluntary participation in this activity, except for the sole negligence of the City of Longview. I certify that I am the parent or legal guardian of the participant named above; that I have read and understood the foregoing release and that I join the release without reservation, granting full consent and authorization for the above named person to participate in the activity

78. Parent/Guardian Full Name:*

    By placing your name in this field you therefore agree to the above stated participation releases and allow your name to be your electronic signature.

79. Date:*
    Date:
Leave This Blank:


80. Submit Submit and Print

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