TOWN OF BLOOMING GROVE SUMMER CAMP PROGRAM 2008

REGISTRATION/REALEASE FORM

Please indicate which sessions of camp your child will be attending, by CIRCLING each that applies:

Week:                    1          2          3          4           5          6          7     

Before Camp:        yes       yes       yes       yes        yes       yes       yes

After Camp:          yes       yes       yes       yes        yes       yes       yes

RESIDENT:__________    NON-RESIDENT:__________  

TOTAL SESSIONS: _________     TOTAL BEFORE/AFTER CAMP SESSIONS: __________

CAMP T-SHIRT SIZE (Please check one):                   ____Youth Large (14/16)

                                                                   ____Adult Small

                                                                   ____Adult Medium

                                                                   ____Adult Large

                                                                   ____Adult X-Large

PARTICIPATION/PERMISSION SLIP & RELEASE

In consideration of the Town granting and continuing permission for use of its facilities, programs and personnel, I hereby authorize my child, whose name appears on this form, to participate in the Town of Blooming Grove Recreation Program to travel to and from facilities and events conducted by the department.

I hereby release the Town of Blooming Grove and its employees from any liability, claims, damage, or expense sustained by my child in connection with such participation.

In case of injury while at the program, I give permission for my child to be taken to a hospital for treatment to include evaluation for injuries, X-ray, and any needed care.  I understand the group leader will try and contact me in case injury occurs.

I have explained to my child that he/she is to obey the Town of Blooming Grove Staff and is to follow rules and regulations set forth by them.

All Fees are non-refundable unless the Town of Blooming Grove cancels the program.

______________________________             _______________________________

Print Full Name                                                              Legal Parent or Guardian Signature

Please list any person(s) who are authorized to pick up your child(ren):

______________________________             _______________________________

______________________________             _______________________________