CUT AND PASTE THIS FORM IN TO EMAIL, FILL OUT AND SEND EMAIL TO: firstname.lastname@example.org
THE BIG PLAYHOUSE
(CHOOSE ANY DAY(S) YOU WISH TO ATTEND)
Summer Camp Registration Form
PART I: ONLY COMPLETE IF YOU ARE DROPPING OFF YOUR CHILD(REN) - ONE-TIME APPLICATION
Child's First Name_________________________ Child's Last Name_________________________ M/F (Circle) Child's Preferred Name________________________________________ Date of Birth (mm-dd-yyyy)___________________________ AGE ____________________ Address____________________________________________________________ City____________________________________ State_______ Zip__________ E-mail Address_____________________________________________________ Parents'/Guardians' Names_________________________________________________________________ Contact number of Parent/Guardian (please say who's number)_______________________________ __________________________________________________________________________________________ ALTERNATIVE CONTACT - for emergency and you cannot be contacted: #1 Name/Relationship__________________________________________________________ Phone Number(s)_______________________________________________________________ #2 Name/Relationship__________________________________________________________ Phone Number(s)_______________________________________________________________ MEDICAL INFORMATION (This information is required by NJS law and Bergen County Health Dept.): Dates of last immunizations: please provide a copy of immunization records for MMR, DPT, Polio, Chicken Pox,Tetanus,Hep B,and HIB ALLERGIES: (Please write "none" if no allergies)____________________________________ _______________________________________________________________________________________________________________ MEDICATIONS (List below, WE DO NOT ADMINISTER MEDICATIONS): (Please write "none" if child does not take any medication.)___________________________________________________ _______________________________________________________________________________________________________________ MEDICAL CONDITIONS including ADHD or any other behavioral conditions within the last 3 years.(Please write "none" if no medical conditions exist.):____________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Physician name and number_____________________________________________________ Insurance name and policy______________________________________________________ Preferred Hospital_____________________________________________________________
I give my permission for _____________________________________to take part in the Summer Day Camp Program at THE BIG PLAYHOUSE Center. This child, to the best of my knowledge, is in good physical condition and is capable of participating in activities like dramatic play, arts and crafts and movement. I understand that activities associated with an indoor camp have an inherent risk factor, and that all appropriate precautions will be taken for the safety of my child. I give my permission to the THE BIG PLAYHOUSE staff and volunteers and/or hospital staff to administer proper medical assistance to the above named participant. I agree not to hold the BARATTA'S ENTERPRISES II, LLC or any of their agents responsible in the event of injury to my child.
Parent or Guardian (Please Print)
__________________________________________________________ Date _______________
Signature of Parent or Guardian
BRING immunization record to: THE BIG PLAYHOUSE 316 KINDERKAMACK ROAD WESTWOOD NJ 07675 on or before first day of camp.
I agree to indemnify and defend THE BIG PLAYHOUSE against all claims, causes of action, damages, judgments, costs or expenses, including attorney fees and other litigation costs, which may in any way arise from me or my family's use of or presence upon the facilities of THE BIG PLAYHOUSE.
Any legal or equitable claim that may arise from participation in the above shall be resolved under New Jersey law.
_____ I HAVE READ THIS DOCUMENT AND UNDERSTAND IT. I FURTHER UNDERSTAND THAT BY SIGNING THIS RELEASE, I VOLUNTARILY SURRENDER CERTAIN LEGAL RIGHTS
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