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Printable Registration Form for Summer Reading

Print out and mail or drop off at the Denver Public Library, 100 Washington Street, P.O. Box 692, Denver, IA 50622

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 Denver Public Library

Summer Reading 2017 Registration Form

 

Child’s Name _________________________________________________

Age_______________________ Grade Completed________________

Parent/Guardian Name_____________________________________

Address________________________________________________________

City______________________________Phone_______________________

 

Emergency Contact Information (In case we cannot contact parent/guardian listed above)

Emergency Contact Name______________________________________________________

Phone number___________________Relationship to child___________________________

Does this person have permission to pick up your child?_____________________________

List any Food/Medical Allergies your child has_____________________________________

Waiver of Liability

 

(Must be read and signed by parent/guardian for child to participate in Summer Reading)

I hereby release The Denver Public Library/City of Denver staff from any liability for injuries incurred by my child while attending the summer reading program. In the event of a medical emergency, every effort will be made to notify me or the emergency contact.    I understand that my child will be expected to follow the safety and behavior rules set up by the library staff.   I give permission for photographs to be taken of my child to be used for publicity purposes.

Parent/Guardian Signature___________________________________________Date__________________     

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