Kensington Recreation Committee
Summer Program in the Park
Registration and Waiver 2010
Child’s Name: _________________________ Phone #: ___________Cell: ___________
Address: ________________________________________________________________
Age: ________ Date of Birth: _____________________ Grade in Sept. ‘10___________
Parents’ Names:__________________________________________________________
E-Mail Address:__________________________________________________________
Regular Session 1:________Session 2:_______Session 3:________Session 4:________Session 5:_______
Extended Day 1:________Session 2:________Session 3:________Session 4:________Session 5:_______
I give my permission for my child to participate in the Kensington Recreation Committee Summer Camp Program, at the Kensington Town Park. As well as attend the beach activity, or off-site substitution, with transportation provided by First Student Busing and walking permission to KES and Library for specials when applicable. I assume all risks and hazards incidental to the conduct of the activities. I do hereby release and hold harmless the Kensington Recreation Committee, coordinator, directors, counselors, and volunteers connected with the program. In case of injury to my child, I hereby waive all claims against the organizers and the supervisors of the activities. I likewise release from responsibility any person transporting my child to and from the activities.
Do you give permission for your child’s photo to be shared on the Rec’s web site, brochure or newspaper? YES NO Please initial________________
I hereby give permission for the Kensington Rec. Camp staff to give my child simple first aid when necessary, or in the event of a more serious accident, for my child to be transported to a hospital to receive emergency medical treatment. I also authorize ambulance/rescue squad attendants to administer such treatment as is medically necessary and I authorize the hospital to undertake examination and emergency treatment if warranted on behalf of my child.
Signature of Parent of Legal Guardian: _________________________ Date: _______
List any special medication, allergies or other conditions that the program director should be aware of: _____________________________________________________________
_______________________________________________________________________
My child: IS a good swimmer______. IS NOT a good swimmer_______.
While at camp parent can be reached at: _______________________________________
In the event of an electrical storm camps must be cancelled and pick up person must be available. Please make arrangements with a friend, relative or other camper’s parents.
Storm Pick Up: _________________________________________Phone #:__________
EMERGENCY, CONTACT: ______________________________Phone #:___________
Alternate pick up persons:
____________________________________________________ Phone #: ___________
Child’s Doctor: _______________________________________ Phone #: ___________
Mail completed form and check payable to the Kensington Recreation Committee: Attn: Marilyn Niles, 95 Amesbury Rd., Kensington, NH 03833. No refund after June 14, 2010.
(Form A REV:2/2010)