2008 Summer Playground Registration

Please circle one park you wish to attend
Wolf's Run
Fairview
Old Orchard
Stephens St.
Keystone

 

Child’s Name______________________________________________Birth Date_____________

Address_______________________________________________________________________

Parent’s Names_________________________________________________________________

Telephone Numbers (Please include Area Code):
Home: (____)_____________Cell: (____)___________ Work: (_____)___________Ext: ________

Emergency Contact & Phone Number (Other than Parent) ______________________________________________________________________________

In consideration of your accepting my child to this program, I, the undersigned, for myself and my child, our heirs, executors, and administrators, do hereby release, absolve, exonerate, indemnify, and hold harmless the Township of Palmer, its successors and assigns, officers, employees, agents, servants, and contractors, from and against all actions, claims, demands, losses, damages, injuries, costs and expenses, including attorney’s fees, arising from participating in the Summer Playground Program, all of its related activities, and the use of the lands and facilities of the Palmer Township.

Signed______________________________________________________Date_______________

MEDICAL INFORMATION Park Location ____________________________

Child’s Name_________________________________________________Age________________

Participating Siblings ______________________________________________________________

Does Participant have any conditions or diseases ________________________________________

List any allergies which require medical treatment ________________________________________

Has Participant been vaccinated for: 3DPT shots________ Polio_______ Mumps___________ Measles___________ Rubella________ Tine_______

Does Participant have any physical restrictions __________________________________________

Is the Participant on any specific medication ____________________________________________

State any conditions the staff should be aware of ________________________________________

My child has permission to have their picture taken by the Park Staff- Yes___No____