Camp Hurricane Activities and Summer Education


(Camp Hurricane Activities and Summer Education)
Hayward Intermediate School ~ 15930 W. 5th Street ~ 715-638-9301
2018 Registration Forms

Child’s Name: ____________________________________________ Gender: M F
Birth Date: _________________________________________________________________
Home Address: _____________________________________________________________
City: ___________________________ Zip Code: _________________________________
Please circle which grade your child will be entering for the ’18-’19 School Year:
4th Grade 5th Grade 6th Grade

Parent/ Guardian 1-Name: __________________________________________________________
Address: ________________________________________________________________________
Please list all phone numbers:
Home: ___________________ Cell: ___________________ Work: ________________
Email: _________________________________________________________________

Parent/ Guardian 2-Name: ________________________________________________________
Address: ______________________________________________________________________
Please list all phone numbers:
Home: ___________________ Cell: ___________________ Work: ____________________
Email: _____________________________________________________________________

List all persons authorized to pick up your child from C.H.A.S.E.:
Including parent names:
Name: ___________________________ Phone: _____________________________
Name: ___________________________ Phone: _____________________________
Name: ___________________________ Phone: _____________________________
Name: ___________________________ Phone: _____________________________

Local Emergency Contact Person (other than parent):

Name: __________________Phone: ________________ Relationship:_______________

Does your child have medical needs: Yes No

If yes, please explain your child’s needs. Please include all allergies and any other special emergency care
instructions or medical information needed by the child care staff.

By registering or participating, the registrant recognizes that all recreational activities have a certain degree of risk and understands that individual accident insurance is not available. I agree to assume all medical costs incurred should injury result from participation in these activities. I hereby agree to hold the Hayward Community Schools, its employees and agents and any and all persons or entities holding thereunder, including any and all policies of insurance, harmless from any and all claims, suits, obligations or other liabilities which arise or may arise out of my child’s participation in such activities and use of the recreational facilities and equipment.

During CHASE pictures or videos are taken of students doing a variety of our activities. These pictures may be used in any number of different ways including; district web pages, and items for local newspaper. When a picture or video is displayed the student(s) will not be identified by name(s). Please complete the consent which indicates your wishes for the use of pictures or videos that include your son/daughter.

_____ I consent to the use of my son’s/ daughter’s picture
_____ I DO NOT consent to the use of my son’s/ daughter’s picture

Start Date: June 11-28, 2018
Hayward Intermediate School
Hours: 7:30am- 11:30am

~The registration fee for C.H.A.S.E. is $25.00 for all 3 weeks. Payment needs to be paid by June 1, 2018.
Please make checks payable to Hayward Community School District.

~The first 100 children that have the registration form and fee paid by June 1, 2018 will be accepted.

First Week:
Northwoods Week

Second Week:
Sports Week

Third Week:
Under the Sea Week

** Fun summer treats will be served.
** Tentative Calendar to follow.

If you have questions or concerns please email Lacie O’Brien at or call 715-638-9502, Kim Lambert at or call 715-638-9508.

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