CUT AND PASTE THIS FORM IN TO EMAIL, FILL OUT AND SEND EMAIL TO: office@thebigplayhouse.com

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_____________________________________________________________

Permission Form

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 

PART II: TO SELECT DAYS AND SUBMIT PAYMENT FOR YOUR CHILD(REN) FOR SUMMER CAMP ACTIVITIES - CLICK HERE