RRC Afterschool Program - 3rd and Spruce

2026 Afterschool Program (3rd and Spruce)

Sept. 8, 2026 - May 28, 2027 | MONDAY - FRIDAY

3:30 p.m. - 7:45 p.m. | Dinner & snack included
REGISTRATION FORM

If this does not apply to you, please enter 'Not Applicable' or '000-000-0000' in the required fields.
FIRST NAME OF CHILD
LAST NAME OF CHILD
BIRTHDATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
AGE
ADDRESS
MOTHERS OR GUARDIANS FIRST NAME
MOTHERS OR GUARDIANS LAST NAME
PHONE NUMBER
Format: (000) 000-0000.
EMAIL

Confirmation Email
MOTHER'S WORKPLACE
MOTHER'S WORKPLACE PHONE NUMBER
Format: (000) 000-0000.
FATHERS OR GUARDIANS FIRST NAME
FATHERS OR GUARDIANS LAST NAME
PHONE NUMBER
Format: (000) 000-0000.
EMAIL

Confirmation Email
FATHER'S WORKPLACE
FATHER'S WORKPLACE PHONE NUMBER
Format: (000) 000-0000.
CHILDS GRADE IN SEPTEMBER 2026
CHILDS SCHOOL
Ethnicity (check one)
Race (check one)
AGREEMENT, WAIVER AND RELEASE FOR MINOR
As we slowly get back to normal following the measures taken to address the threat from COVID-19, we believe it is important for you to understand and acknowledge the following. An inherent risk of exposure to COVID-19 exists in any public place where people are present. COVID- 19 is an extremely contagious disease that can lead to severe illness and death. According to the Centers for Disease Control and Prevention, senior citizens and individuals with underlying medical conditions are especially vulnerable. By having your child participate in the activities of the Reading Recreation Commission, you and your child are hereby acknowledging and assuming all risks related to exposure to COIVD-19, including the risk that your child will become a carrier of COVID-19 and expose others as a result.
Initials
In consideration for being permitted by the Reading Recreation Commission ("RRC") to participate in the afterschool program, I, the UNDERSIGNED, certify that I have legal custody or am the natural or appointed guardian of said minor, and I agree to be bound by the following: 1. Participation in Program: The Afterschool Program provides a variety of activities for children including, but not limited to, contact sports, playing on playground equipment, arts and crafts, social activities, active games and quiet games. Some hazards associated with these activities include but not limited to, injuries associated with contact sports and injuries associated with playing on playground equipment, sun burns, heat exhaustion, insect bites, bee stings, and minor injuries associated to using scissors, game equipment and various other supplies and materials. Ages for the program are: 1st 12th graders! 2. Condition of Program: I understand that the abovementioned programs are not child care, but are considered by RRC to be drop-in recreational programming, meaning that children will not receive structured care and supervision. Children have the right to come and go from RRC facilities and staff will not supervise them to prevent them from leaving. 3. Medical Attention: I hereby give my consent that in the event said minor should require medical treatment while under the supervision of RRC's personnel in connection with the above described activity, such personnel may authorize treatment that he or she deems necessary. I also agree to pay all medical, hospital or other expenses which said minor may incur as a result. 4. Waiver, Release and Indemnification: I hereby waive, release and discharge any and all claims in advance against RRC (including its directors, officers, employees and agents) from and against any and all liability arising out of or connected in any way with said minor's participation in the above described activities, even though that liability may arise out of negligence or carelessness on the part of RRC (or its directors, officers, employees or agents) for damage for personal injury, death or property damage which I or said minor may have or which may hereafter accrue as a result of participation in said activity. It is understood and agreed that this waiver, release and assumption of risks is to be binding on the heirs and assigns of said minor and the undersigned. I further agree to reimburse or make good any loss or damage or cost that RRC (or its directors, officers, employees or agents) may have to pay if any litigation arises on account of any claim made by said minor or by anyone on behalf of said minor. 5. Promotion: I hereby give consent to the Reading Recreation Commission to photograph said minor. I understand the picture may be included in program promotional materials, and/or in the promotion of RRC's Afterschool Program in the newspaper, slide shows or other media. Any use of pictures of playground participants are for RRC's charitable purposes only.

I have carefully read this Waiver or Liability, Medical Release and Indemnification Agreement and fully understand its contents. I am aware that this is a release of Liability and a contract between myself and the Reading Recreation.
SIGNATURE OF PARENT / GUARDIAN
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
EMERGENCY INFORMATION

If this does not apply to you, please enter 'Not Applicable' or '000-000-0000' in the required fields.
FIRST NAME OF CHILD
LAST NAME OF CHILD
BIRTHDATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ADDRESS
MOTHERS OR GUARDIANS FIRST NAME
MOTHERS OR GUARDIANS LAST NAME
DAY PHONE
Format: (000) 000-0000.
CELL
Format: (000) 000-0000.
MOTHER'S WORKPLACE
MOTHER'S WORKPLACE PHONE NUMBER
Format: (000) 000-0000.
FATHERS OR GUARDIANS FIRST NAME
FATHERS OR GUARDIANS LAST NAME
DAY PHONE
Format: (000) 000-0000.
CELL
Format: (000) 000-0000.
FATHER'S WORKPLACE
FATHER'S WORKPLACE PHONE NUMBER
Format: (000) 000-0000.
NAME OF CHILDS PHYSICIAN OR SOURCE OF MEDICAL CARE
ADDRESS OF PHYSICIAN
PHONE
Format: (000) 000-0000.
ALLERGIES OR SPECIAL CONDITIONS
MEDICATIONS DOSAGE TIMES TO BE TAKEN
RESTRICTED ACTIVITIES IF ANY
HEALTH INSURANCE
POLICY #
The following individuals are authorized to drop off (sign in) and pick up (sign out) my child:

If this does not apply to you, please enter 'Not Applicable' or '000-000-0000' in the required fields.
First and last name
Phone
Format: (000) 000-0000.
First and last name
Phone
Format: (000) 000-0000.
First and last name
Phone
Format: (000) 000-0000.
My child is permitted to walk to and from the program
In the event of an emergency I understand that I am responsible for all expenses should my child need medical treatment. I give my permission for the Reading Recreation Commission staff to authorize necessary medical treatment including authorizing my child to be taken to the nearest hospital facility in the event of an emergency. I give my permission for Reading Recreation Commission staff to administer my child’s medicine according to my written instructions on this form. I will be asked to pick up my child from playground if he/she has a contagious illness or condition.
SIGNATURE OF PARENT / GUARDIAN
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Program that you are registering for:
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Afterschool Program (3rd & Spruce)
$80.00

Total

$0.00

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REGISTRATION FORM

AGREEMENT, WAIVER AND RELEASE FOR MINOR

EMERGENCY INFORMATION

The following individuals are authorized to drop off (sign in) and pick up (sign out) my child:

Program that you are registering for:*

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