Summer Camp 2019 Registration Form
Child's First Name/Last Name *
Your answer
Grade in September '19 *
Your answer
Age *
Your answer
Please indicate: *
Address, Town, State, Zip *
Your answer
Parent/Guardian Name 1 & cell phone # *
Your answer
Parent/Guardian Name 2 & cell phone # *
Your answer
E-mail address *
Your answer
Before and After Care Programs
Before Care 7:15-8:40 AM $8/day $30/week Days/Weeks
After Care Hours 5-6 PM-Please check days/weeks your child will be attending. $8 per day/$30 per week
Camps, please select the camp your child will be attending, number of days per week
SUMMER RECREATION FULL DAY CAMP
Please choose 5 day or 3 Full day camp
SUMMER RECREATION 6 HOUR CAMP
Please choose 5 day or 3 day 6 Hour camp
Please indicate hours attending between 8:30 and 5. For example 8:30-2:30, 9-3, etc.
PRE-K STORY TIME CAMP
Pre-K Story Time ages 3-4 Please check one
PreK Story Time Camp - Please check time attending
WEEKS AND DAYS ATTENDING
Please select the weeks your child will be attending camp, either all 7 weeks or individual weeks of your choice.
Please select days your child will be attending camp
Safety Town, Mad Science and Sports Camps
9. Safety Town-Grade K-1
Mad Science Camps
Mad Science Camps
SPORTS CAMPS
Please select Sports Camps your child will be attending.
TRIPS -ALL PAYMENTS DUE UPON REGISTRATION. TRIPS ARE NON-REFUNDABLE. REGISTER EARLY AS TRIPS FILL UP QUICKLY.
Please fill out permission slips located on main page
TRIP T shirt size
FEES AND PAYMENT
Camp Fee Enclosed
Your answer
Before Care Fee Enclosed(if applicable) $30/week, $8/day)
Your answer
After Care Fee Enclosed(if applicable) $30/week, $8/day)
Your answer
Trip T-Shirt Fee enclosed $6(If Applicable)
Your answer
Total Trip Fee Enclosed
Your answer
Total Fee Enclosed
Your answer
Payment method- check one *
Required
If using a credit card, please call the office with your number - 201-843-1142 ext. 2314. For cash, it must be brought to the office at 355 Mayhill Street - call for appointment. Checks can be sent to: Saddle Brook Board of Education, Community Programs Office, 355 Mayhill Street, Rm. 124, Saddle Brook, NJ 07663.
EMERGENCY CONTACT INFORMATION-MEDICAL RELEASE FORM
Child's First Name, Last Name, Age *
Your answer
1. Emergency Contact Person designated to pick up child other than parent/guardian in case of emergency. Please list name, phone number and relationship to child. *
Your answer
2. Emergency Contact Person designated to pick up child other than parent/guardian in case of emergency. Please list name, phone number and relationship to child.
Your answer
In the event that I am unavailable for the purposes of providing parental consent, I hereby authorize the physician(s) and staff at the local hospital to provide such hospital care that includes routine diagnostic procedures and medical treatment as necessary to my minor son/daughter. I understand that consent and authorization herein granted does not include major surgical procedures and are valid only during camp.
I agree to the statement above *
Signature and date agreeing to statement above *
Your answer
Please list allergies that the instructor/physician should be aware of *
Your answer
Please list physical conditions that the instructor/physician should be aware of (recurring illness, disabilities, chronic illness, etc.) *
Your answer
My child has an epipen *
Physician Name and phone number *
Your answer
INSURANCE INFORMATION- In the event of illness or injury requiring treatment or hospitalization, family medical insurance must be used. The parent/guardian is required to have medical coverage/hospitalization for your child(ren). Proof of coverage is required before child is permitted to attend any summer camp. THE BOARD OF EDUCATION DOES NOT INSURE YOUR CHILD
Insurance Company Name and Policy Number *
Your answer
PARENTAL CONSENT- : I hereby give my consent for my child to participate in all activities in Tennis Camp, Fast Break Basketball Camp, Let The Games Begin Camp, Yoga, all Summer Recreation Camps, Pre-K Storytime Camps, Safety Town, Mad Science Camps and all other camps and all trips. I declare that my child is in good physical condition. I hereby give the staff permission to render such medical care as, in their judgment may seem advisable for my child. I hereby discharge the staff, The Saddle Brook School District, the Town of Saddle Brook, its agents, employees, appointed officials, volunteers, commissions or associations from any and all claims or actions for losses, damages, or personal injuries due to participation in the camps/trips. I also hereby state that I, the parent/legal guardian, have adequate medical coverage and will not hold the staff of the camps liable for injuries incurred during the camp session.
I give my consent for my child's participation in the camps/trips as per statement above *
Parent/Guardian Consent Signature and date *
Your answer
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