MY PHIT Registration Forms

M.Y. P.H.I.T.
(Mentoring Youth in Physical Health Initial Tasks)
MY PHIT is a program aimed at providing mentorship and positive role models for
middle school aged youth (5th –8th) This program is targeted at improving citizenry
activities, health, and wellness for youth in Yuma County. Each session will provide
various activities and mentoring opportunities, meant to build youth by team building
and pay-it-forward mentoring and will allow them to discover new healthy snacks
and meals. We will meet each Wednesday (Feb. 4th through Mar. 11th) from 3:45 to
5:15 p.m. and on Early Release days from 2:15 to 5:15 p.m.
Sponsored by collaborative efforts between the WRAC, Yuma County Extension Office, Yuma County
Department of Human Services, Wray Community District Hospital, and Wray Police Department.
Registration Deadline: Friday, January 23rd
Drop off form at the WRAC front desk
or mail in registration & payment to the WRAC
Due to new funding, any participant missing more than 2 sessions will forfeit spot to the next child on the waiting list.
Mail-In MY PHIT Registration Form
Participant’s Name:______________________
$10 per participant
Participant’s Grade Level:_________________
5th-8th Grade: Wednesdays 3:45 - 5:15p.m.
Parent’s Name:__________________________
On Early Release days: 2:15 - 5:15 p.m.
Feb. 4th—Mar. 11th (6 weeks)
City:____________ State:______ Zip:_______
Limited class space available
Phone Number:_________________________
Mail completed form with payment to:
Emergency Contact:______________________
P. O. Box 447
Contact Phone Number:___________________
Wray, Co. 80758
Child’s Birthday: ________________________
T-Shirt Sizes: Youth S M; Adult S M L (If your child wears a Youth L we will order a Adult S)
Food Allergies and/or Health Concerns:_______________________________________________
*Occasionally, we may be leaving the site for various activities. There will be no transportation for these
activities, so the days will be planned around the weather. We will be back at the WRAC in time for the
kids to be picked up.
I give permission for my child to participate in these activities: ___ Yes ___ No
Parent Signature ___________________________________________________
The MY PHIT program is open to all participants, ages 5th through 8 th grade. Program enrollment is kept at a reasonable participation fee ($10) per the Department of Human
Services Contract (Part III (B)). Registrations are taken along with payment until program size limits are met (limited to 15 per session). An additional waiting list is kept in
case a registered participant drops from the program.
Hi, Parents/Guardians,
We are so excited to have your child participate in our program! Here is
a MY PHIT schedule:
 February 4th, 3:45 to 5:15 p.m., First Session
 February 11th, 2:15 to 5:15 p.m. (Early Release)
 February 18th, 3:45 to 5:15 p.m.
 February 25th, 3:45 to 5:15 p.m.
 March 4th, 3:45 to 5:15 p.m.
 March 11th, 2:15 to 5:15 (Early Release), Last Session
I, (print name)_________________________________________, parent or official
guardian of (child’s name)________________________________hereby grant
permission to the WRAC, to take and use: photographs and/or digital images of my
child for use in news releases and/or educational materials as follows: printed
publications or materials, electronic publications, or Web sites. I agree that my child’s
name and identity: may be revealed in descriptive text or commentary in connection
with the image(s). I authorize the use of these images without compensation to me. All
negatives, prints, and digital reproductions shall be the property of the WRAC.
(Signature of Parent or Guardian)
I, _________________________________________ (nombre de impresión), padre o guardián
oficial de (nombre del niño) ________________________________por la presente conceder
permiso a los WRAC para adopter y utilizar: fotografías y/o imágenes digitales de mi hijo para
utilizan en los comunicados de prensa y materiales educativos. Estos materiales pueden incluir
publicaciones impresas o electronicas, de sitios Web o de ostras comunicaciones electronicas.
Ademas estoy de acuerdo en que mi hijo nombre e identidad: puede ser revelado en un texto
descriptivo o comentario en relación con las imágenes. Autorizo el uso de estas imágenes sin
compensacion para mí. Todos negativos, impresiones y reproducciones digitales serán propiedad
de la WRAC.
(Firma del padre o tutor)