2. PlayNet Emergency Form
4. Program Information
6. PlayNet Location:*

   1. Sunrise Elementary
   2. Happy Acres
   3. Kane Meadows

   1. Legacy Creek
   2. Lexington Athletic Complex

   1. Quail Creek
   2. West Lake
8. Days*

   1. Monday/Wednesday
   2. Tuesday/Thursday
12. Children
14. Family Last Name*
16. Child 1 Name*
17. Age*
18. Program*

    1. Regular
    2. Junior
20. Allergies, Medications, Special Concerns
22. Child 2 Name
23. Age
24. Program

    1. Regular
    2. Junior
26. Allergies, Medications, Special Concerns
28. Child 3 Name
29. Age
30. Program

    1. Regular
    2. Junior
32. Allergies, Medications, Special Concerns
34. Parent 1 Information
36. Name*
38. Address
40. City*
41. State*
42. Zip Code*
44. Home Phone Number
45. Cell Phone Number
47. Parent 2 Information
49. Name
51. Phone Number
52. Cell Phone Number
56. Emergency Contacts
58. Please list two emergency contact we can call if we are unable to reach you.
60. Name*
61. Phone Number*
63. Name*
64. Phone Number*
66. Please list anyone NOT allowed to pick up your child.
68. Name(s)
72. I give permission to Blaine Staff to perform minor first aid if required.*

    1. Yes
    2. No
74. I give my child/ren permission to walk/bike home from Play-Net Blaine

    1. Yes
    2. No

    (Only applies to children in the regular PlayNet Program and NOT to the Juniors)
76. Consent to Release of Information and Liability

    In consideration of your accepting this application, I authorize the City of Blaine to disclose to the City’s insurer, attorney, staff, coaches, participants and other personnel involved in this program the following information: name, address and telephone number. This information shall be used for the purpose of program administration. This consent to release information shall expire one year from the date of execution. I understand that the records are protected under the state and federal privacy regulations. I also understand that I may cancel this consent by a writing to that effect at any time prior to the information being released. I give my consent to use any photograph or video tape taken of myself for future promotional or marketing materials. In consideration of the City providing the registered activities, I agree to not hold the City liable for any claim resulting from participation in any such activity, including claims for injuries, death and resulting attorney fees. The completion of your registration signifies your acceptance of this consent.

78. By checking this box, you agree to the waiver and liability clause above. *

    1. I agree
Leave This Blank:


80. 1. Receive an email copy of this form.
81. Email address

    This field is not part of the form submission.

82. Submit

* indicates a required field