Return this page to Clinton Parks and Recreation Office 560 High Street Clinton MA 1 2015 TEEN ADVENTURE PROGRAM REGISTRATION FORM
Description of program: Where: Head Start Building, Clinton MA
What: The teen adventure program is design to give teenagers a safe and constructive place to spend their summer vacation. Each week participants will get the opportunity to participate in games, special events, swim, and go on fieldtrips. We have designed this program exclusively for teenagers and promise a summer they won’t soon forget.
When: Seven week program, Monday-Friday, June 29th-August 14th
Ages: Participants must be entering grades 6th-9th grade. Those entering 10th grade may apply for our CIT program. **Please not space is limited to 25 participants; please get your registration in early.
Time: 8:30am-3:00pm (morning drop-off 7:30am—8:30am***) First Child Additional Children in Family** Individual Week Cost $125.00 per week $115.00 per week Full Summer Cost $832.00 $805.00 Weekly Field Trips ONLY (if $75.00 No Discount you would just like to go on the field trips)
***Early drop off is an additional $20.00 per week, per child Registration has to be filled out for each camper.
Week(s) your child will be attending: (Please check)
( ) WEEK 1 (June 29th-July 3rd) ( ) WEEK 2 (July 6th -10th) ( ) WEEK 3 (July 13th -17th)
( ) WEEK 4 (July 20th -24th) ( ) WEEK 5 (July 27th – July 31st) ( ) WEEK 6 (Aug 3th -7th)
( ) WEEK 7 (Aug 10th -14th) ( ) ALL SEVEN WEEKS
Total: ______
Week(s) your child will need early drop off. This service is $20.00 per week.
( ) WEEK 1 (June 29th-July 2nd) ( ) WEEK 2 (July 6th -10th) ( ) WEEK 3 (July 13th -17th)
( ) WEEK 4 (July 20th -24th) ( ) WEEK 5 (July 27th – July 31st) ( ) WEEK 6 (Aug 3rd -7th)
( ) WEEK 7 (Aug 10th -14th) ( ) ALL SEVEN WEEKS
Grand Total Owed: ______
Return this page to Clinton Parks and Recreation Office 560 High Street Clinton MA 2 PARTICIPANT INFORMATION (Please Print)
Participant Name: ______Age: ______
Date of Birth: ______M/F______Grade (fall 2015) ______
Address: ______Home Phone Number: ______
T-Shirt Size: Youth S, M, L, XL - Adult S, M, L, XL
PARENT / GUARDIAN: (Please Print)
Mother: ______(_____)______(_____)______First Last Work Phone Cell Phone
Father: ______(_____)______(_____)______First Last Work Phone Cell Phone
Email: ______
ALTERNATE EMERGENCY CONTACT:
Name/Relationship:
______
Phone: ______
PICK-UP LIST:
List individuals other than parents/guardians that are allowed to pick-up the participant
Name: ______
Relationship: ______
I give Clinton Parks & Recreation permission to use pictures taken during the program on their website and in promotional materials.
INJURY WAIVER: In consideration of participation of the minor player named above in this recreation program, the undersigned parent or guardian hereby consents to his/her participation and releases and holds harmless the Towns of Clinton and the Clinton School District and their officers, agents, and employees from any liability for, and waives all claims, suits, or causes for action that the undersigned, as parent or guardian, and said minor, either before or after he/she may reach his/her age of majority, may have now or hereafter based on or arising from, any injury suffered or incurred by the minor player as a result of, or in conjunction with, his/her participation in said recreation program. Such waiver and release to be in effect without regard to whether such injury is the result of or caused by the fault of the town of Clinton or the Clinton School District or any of their officers, agents, or employees. This instrument is intended to take effect as a sealed instrument. I further certify that my child is medically fit to participate in the above recreation program.
SIGNATURE ___ (Parent/Guardian) DATE ____
PARTICIPANT HEALTH RECORD
Return this page to Clinton Parks and Recreation Office 560 High Street Clinton MA 3 The following information is to be completed by the parent. It will be held confidential and will be only used to benefit your child. Please use additional paper if needed.
Are there any significant findings that could influence the child’s adaptations to a child care/camp setting? (.i.e., physical handicap, sensory problems or loss, developmental irregularities)
______
______
List any diet modifications or special medications we should know about and special medications they will need on hand while attending the program:
______
New this year is our summer lunch program. Each day children will receive FREE hot/cold lunch. Please note any diet restrictions or allergies (Gluten Free, Nut Allergy, Vegan, etc)
______
______
In case of emergency, I hereby give permission to the camp staff and medical personnel selected by the staff, in my absence, to act as my agent in securing proper medical treatment for my child as named above, including hospitalization, routine tests, X-rays and other medical treatment. Every possible effort will be made to contact parents in the event of an emergency.
______
PARENT SIGNATURE:
______
DATE
Return this page to Clinton Parks and Recreation Office 560 High Street Clinton MA 4