Registration – Rehab Associates of WNY

Child's First Name

Child's Last Name

Child's Date of Birth

Parent's First Name

Parent's Last Name

Parent's Primary Phone Number

Parent's Secondary Phone Number

Parent's Email

Child's Allergies

Does you child require an EPI Pen for any of their allergies?

No Yes (Please be sure your child comes to camp with one)

Additional information about your child

Emergency Contact #1 Full Name

Emergency Contact #1 Relationship

Emergency Contact #1 Phone Number

Emergency Contact #2 Full Name

Emergency Contact #2 Relationship

Emergency Contact #2 Phone Number

How did you hear about us?

Flyer Teacher Therapist Other

Camp Requirements

_ I understand that my child should arrive to camp with sunscreen already applied, a labeled towel (may be left at the facility), a water bottle, and wearing sneakers appropriate for activity.

Informed Consent/ Waiver of Liability

_ This agreement between the above named parties and the M.O.G. Inc, Grand Island Physical Therapy PC, Trilogy Wellness Inc., and Rehab Associates Physical Occupational Therapy of WNY PLLC, (Corporation)allows the child access to the Corporation's facilities during their program's hours of operation. I acknowledge that I have voluntarily chosen to enroll my child in a program of progressive exercise. I further acknowledge being familiar with the inherent risk of personal injury to my child when undertaking such physical activity. I herby affirm that my child is in good physical condition and does not suffer from any disability that would prevent their participation in this exercise and enrichment program. I understand that the use of the facility is solely at the participant's own risk. I herby release, waive, and discharge the Corporation and its, officers, agents, and employees from all liability to myself and my child for any loss or damage, and any claim or demand therefore on account of injury to my child or property or resulting in deal of my child, whether caused by the negligence of the releases of otherwise, while my child is in, upon, or about the premises or any facilities or equipment, therein. I understand that lost or stolen property is not the responsibility of the Corporation.