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Step One

Child's Last Name*
First Name*
Street Address*
Apt. #
City*
Zip*
Gender*
1. Male
2. Female
Date of Birth*
Date of Birth
Entering Grade in Sept. 2018*
School*
Is your child fluent in English?*
1. Yes
2. No
Does your child have an IEP or 504?*
1. Yes
2. No
(if yes, please complete the information below so we can best accommodate your child. Please note: We do not reserve placement.)
1. Tell us about your child’s special need (i.e. educational, emotional, and/or physical)
2. Does your child require a smaller class size or extra assistance during the school day?
1. Yes
2. No
If yes, please describe these modifications
An IEP or 504 information and interview (parent with child) is required before registration.
CONTACT INFORMATION
Parents or Guardians - Name & Contact Information
Home Number*
Mother Name
Father Name
Mother work number
Father work number
Mother cell phone
Father cell phone
Mother or Father - Best Email to be reached at*
Emergency Contact Person other than parent of guardian (2 names required):
Name*
Relationship*
Contact #*
Name*
Relationship*
Contact #*
ARRANGEMENTS FOR DISMISSAL
My child
(TYPE) Child's Name*
is to be dismissed from Camp in the following manner:
Child is to be released to the following person(s):
Name*
Relationship*
Contact #*
Name
Relationship
Contact #
Name
Relationship
Contact #
Special Instructions
RELEASE OF LIABILITY
In consideration of your acceptance of my child
(TYPE Child's Name)*
for his/her participation in the activities/programs of the City of White Plains; including permission to participate in busing, swimming, and trips. I consent to my child being videotaped/photographed for publication/broadcast/website. I agree that I am aware of the inherent dangers and risks involved in these activities/programs including bodily injury which may be the result of strenuous activity or other causes related to these activities/programs. I agree to, for my child, release and hold harmless the City of White Plains, its officials, officers, agents, employees, and volunteers, from and against any and all liability, damage or claim of any nature arising out of or in any way related to my child’s participation in these activities/programs except those things caused by the sole negligence of the City. I understand that the City of White Plains does not provide accident or medical insurance and I am financially responsible for any and all medical expense whatsoever. I am advised to consult my child’s physician before allowing my child to participate in any strenuous activity. I have read, understand, and agree with the terms of this release.
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Step Two

(TYPE) Child's Name*
It is required by State Law to provide immunization information. This form must be filled out completely. NO ONE will be accepted into camp if any part is not completely filled out.
A. It is required by State Law to provide immunization information. This form must be filled out completely. NO ONE will be accepted into camp if any part is not completely filled out.
If your child has NOT received immunizations, indicate “0’s” in the date boxes.
B. Immunization Records and Dates
1. Diphtheria/Tetanus Toxid – 4 Doses
Please enter dates below*
2. Oral Polio Vaccine – 3 Doses
Please enter dates below*
3. Measles /Mumps/rubella 2X - MMR
Please enter dates below*
4. Haemophilus Influenza Type B
Please enter dates below*
5. Hepatitis B
Please enter dates below*
6. Varicella (Chicken Pox)
Please enter dates below*
C. Allergies or Special Medical Problems (Please list)
D. Required Medication (Please list the medications your child taking):
Note: If your child is required to take any type of medication during camp hours (including over the counter medication), MEDICAL AUTHORIZATION must be provided by your PHYSICIAN and filed with the Camp Director.
Any restrictions to physical activities while taking this medication? *
1. Yes
1. No
If you answered YES above, what are the restrictions?
E. Sunscreen - Campers must be able to apply sunscreen on their own. Staff is not allowed to apply sunscreen to your child.
F. EpiPens and Inhalers - If needed, your child must be able to self-administer their EpiPen or inhaler.
G. In case of injury or illness to my child, I authorize a camp representative to transfer my child to a hospital or other emergency medical facility for treatment.
Doctor's Name*
Doctor's Phone*
Health Insurance Carrier*
Identification Number*
I have read, understand, and agree with the terms of this release.
Parent/Guardian Signature
Date
Date
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Step Three

REGISTRATION CHANGES AND REFUND POLICY
Refunds will only be processed due to an illness or accident. Parents requesting a refund must notify the City of White Plains Recreation & Parks Department in writing, accompanied by a doctor’s note.
Note: Deposits are non-refundable. A $25 service fee will be charged for all changes that involve a financial transaction resulting in a reduction in enrollment.
Balance payment is due in full, no later than May 31, 2018.
I have read, understand, and agree with the terms of this policy.
Parent/Guardian Signature
Date
Date
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Step Four

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Summer Camp Registration - Panawok - 2018

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