You must have JavaScript enabled to use this form. Applicant Information Full name Birthdate Applicant Address Address City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Home phone Cell phone Email Parent/Guardian Information Parent/Guardian 1 name Parent/Guardian 1 home phone Parent/Guardian 1 work phone Parent/Guardian 1 cell phone Parent/Guardian 1 email Parent/Guardian 2 name Parent/Guardian 2 home phone Parent/Guardian 2 work phone Parent/Guardian 2 cell phone Parent/Guardian 2 email Health Information Primary disability Allergies Medical codes (check all that apply) A-Allergies C-Coronary/Heart Condition D-Diabetes DS-Down Syndrome H-Hearing Impairment S-Seizures V-Visual Impairment WC-Wheel Chair Programs Programs Day Programs at Centennial Sportsplex (Monday-Thursday) Day Programs at Bellevue Community Center (Monday and Wednesday) Day Programs at Madison Community Center (Monday and Wednesday) Day Programs at Coleman Park Community Center (Tuesday and Thursday) Day Programs at Cleveland Park Community Center (Tuesday and Thursday) Family Events Best Buddies Community Days Sports Leagues (flag football, soccer, basketball, volleyball, floor hockey, and bocce) Special Olympics Activities Visual Arts (Art, Pottery, Drawing, etc.) Performing Arts (Singing, Acting, Film, etc.) Fitness and Exercise Classes (Yoga, Boot Camp, Boxing, etc.) Outdoor Recreation (Kayaking, Canoeing, Sailing, Hiking, and Camping) T-Shirt T-shirt size S M L XL 2XL 3XL 4XL Acknowledgement/Certification I hereby make application for to participate in planned recreational activities conducted by the Metropolitan Board of Parks & Recreation. I understand that transportation will only be provided for certain designated activities throughout the year. I also understand that the Recreation Staff will provide reasonable supervision, but will not be held liable in the event of an accidental injury. Parent/Guardian name By checking this box, I certify that I agree with the statement above. Leave this field blank