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Bring Your Child to Work Day 2018
Volunteer Registration Form
Registration is a two-part process. This form alone does not guarantee a spot. Payment must be made subsequently to complete registration.
Be sure to pay for the correct number of participants in the payment screen.
Sponsor Information
This section should contain
your
information.
*
Indicates required field
Sponsor Name
*
First
Last
Enter your full name (first and last).
Phone Number
*
Provide a phone number at which you can be reached during the day (work phone preferred).
Work Email
*
Provide your official duty email here.
Building Number
*
Provide on-post building number or street address.
Category
*
Active Military
DoD Civilian
DoD Contractor
Other
Select the category that best applies to your position here at Picatinny Arsenal.
If you chose DoD Civilian, please select the sub-category that most applies to you.
*
Army
Navy
DCMA
Contracting ACCNJ
Only fill this out if you are a DoD civilian. Select which fits you best.
Relationship to Youth Participant(s)
*
Parent/Step-parent
Grandparent
Aunt/Uncle
Friend/Neighbor
Select the relationship you have to the youth participant as is best defined by the available choices in the drop down menu.
Youth Participant Information
This section should contain information for
all
youth who will be attending this event. Every field must be complete. For technical questions, please contact
[email protected]
.
Child #1
*
Name #1
*
First
Last
Provide the first and last name of Child #1.
Age
*
7
8
9
10
11
12
Select the age of Child #1.
Grade
*
1
2
3
4
5
6
7
8
Select the grade of Child #1 for the 2017-18 academic year.
Child #2
Name #2
*
First
Last
Provide the first and last name of Child #2.
Age
*
7
8
9
10
11
12
Select the age for Child #2
Grade
*
1
2
3
4
5
6
7
8
Select the grade of Child #2 for the 2017-18 academic year.
Child #3
Name #3
*
First
Last
Provide the first and last name of Child #3.
Age
*
7
8
9
10
11
12
Select the age of Child #3.
Grade
*
1
2
3
4
5
6
7
8
Select the grade for Child #3 for the 2017-18 academic year.
Child #4
Name #4
*
First
Last
Provide the first and last name of Child #4.
Age
*
7
8
9
10
11
12
Select the age of Child #4.
Grade
*
1
2
3
4
5
6
7
8
Select the grade of Child #4 for the 2017-18 academic year.
Emergency Medical and Contact Information
Provide all requested information for the youth participant(s) in this section. In the event of a medical or other emergency, this information is imperative to the safe handling and transport of all participants.
Health Insurance Company Name
*
If you have multiple insurance carriers, enter the information for the child's primary insurance provider.
Policy Number/ID
*
If you do not have a policy number or ID, provide the group number/ID. If this information requires inputting someone's social security number, please enter the text "SSN". DO NOT provide a social security number in this form.
Health Insurance Policy Holder Name
*
First
Last
Policy Holder's Relationship to Youth
*
If you have a secondary insurance (i.e. you are registering a child under different insurance), enter the information here.
*
Provide company name, policy number/ID or group number/ID, and policy holder name.
Emergency Contact Name
*
First
Last
Emergency Contact Phone Number
*
Emergency Contact Phone Number (Alternate)
*
Life-threatening allergies?
*
Yes (if so, provide details in provided space)
No
If yes to above, provide information regarding necessary treatment/medication.
*
List any medical conditions, allergies, or other things we should be aware of, relating to the health & well being of this youth participant. If there are none, put "N/A".
*
Women in Defense
Are you interested in receiving Picatinny Chapter event information straight to your inbox? Don't wait for the "What's Happening at PIcatinny?" email each week - join WID today! Members have access to all the info as it's happening and we can email you directly! Get the inside track on leadership events, training opportunities, golf outings, scholarship opportunities, and so much more!
WID Membership
*
I would like more information about WID membership.
I am not interested.
I am already a member.
Payment Information
You will be billed
$12
per child.
No cash payment will be accepted.
A link to provide payment will be provided once this registration form is submitted. If you complete this form but do not provide payment, you will risk losing you spot(s) for the event.
Registration is a two-part process. This form alone does not guarantee a spot. Payment must be made to complete registration.
Authorization and Release
I authorize the Picatinny Chapter of Women in Defense to take/use photographs of the youth participant identified in the form, above. These photographs may be portrayed in print and electronic media and will depict the youth participant as an attendee of the 2018 Bring Your Child to Work Day and/or Introduce a Teen to Engineering programs.
In the event of an emergency, I authorize the Picatinny Chapter of Women in Defense members and volunteers to act for me, according to their best judgement, in any emergency requiring immediate medical attention. I have provided instructions and information regarding any life threatening allergies, medications, or conditions for this youth participant in the designated section of this form.
By typing my name in the field below and submitting this form, I hereby authorize my consent and agreement to the terms outlined herein.
Name (Represents Legal Signature)
*
First
Last
Submit
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