Summer Camp 2013 Registration Packet

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Transcript of Summer Camp 2013 Registration Packet

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    Morrisville Parks, Recreation& Cultural Resources

    2013- 2014 Youth & Preschool Programs Master Registration

    Participants Name:Add ress:

    Home Phone #:City:

    State: Zip:Email Address:*Email addresses may be subject to disclosure under the Public Records Law

    Are you a Resident of Morrisville? Yes / No

    Age: Date of Birth: Gender: Male / Female

    Parent or Guardian Information:Primary Guardian Name: Contact Phone #:Secondary Guardian Name: Contact Phone #:Are there any medical conditions or allergies that we need to be made aware of? (Use space provided)

    REFUND POLICYALL REQUESTS FOR REFUNDS MUST BE IN WRITING. A full refund is given if the Parks, Recreation & Cultural ResourcesDepartment cancels a program, facility rental or athletics league. A full refund minus a $5.00 administrative fee will beconsidered if written notice of registration cancellation is given at least 14 days prior to the program starting or athleticteams being selected. If notice is given less than 14 days prior to the program starting or teams being selected, a 50%refund will be given if the enrollment can be filled from a waiting list. Once a program has started or teams have beenselected, a 50% refund will only be given if the enrollment can be fil led from a waiting list. No refunds are considered aftercompletion of programs, facility rentals or athletic leagues. Medical hardship cases will be handled at the discretion of theDirector of Parks, Recreation & Cultural Resources. If a medical hardship is granted, a refund may be given minus a $5.00administrative fee, if received prior to program starting, athletic teams being selected or if the enrollment can be filled froma waiting list. After a program has started or teams have been selected then 50% of the registration fee will be consideredfor refund if the enrollment cannot be filled from a waiting list (medical hardship cases only).

    CONSENT TO PARTICIPATE WAIVERI, for myself or as parent or guardian, hereby assume all the risks and hazards incidental to the conduct of the activities, andtransportation to and from the activities. I release, absolve and indemnify the Town of Morrisville, employees of the town,volunteers, contractors and/or sponsors from all risks and hazards associated with the activities and in the event of injury,do expressly waive all claims against them. I understand that no insurance coverage is provided by the Town of MorrisvilleParks, Recreation and Cultural Resources Department. I also agree that participants likeness may be photographed orvideotaped and that such image may be published in an outlet used to promote or publicize town programs.Participant Signature:(If participant is under 18 years of age, please use parent/guardian signature.)

    Date:

    iorrisvllle Parks, Recreation& Cultural Resources

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    Participants Name (First, Middle, Last):

    Morrisville Parks, Recreation& Cultural Resources

    2013- 2014 Youth & Preschool Programs Master Registration

    Age ( as of Aug. 31, 2013): (13- 14 School Year): School (13- 14 School Year):

    Please check all that apply to your child, or check None for those that dont apply:DAllergies/ Intolerances & Actions to relieve Reactions (please list): C None

    Nickname:

    DMedications (please list): C None

    Will medication need to be administered to your child at our programs? C Yes C No*lf yes, a Medication Card will need to be filled Out Ofl your childs first day of the program.DOther Health Conditions: C None

    DSpecial Circumstances/Requests: C None

    Family Information:Please complete information on both parents, then check to indicate which parent to contact for payment and other questions.C Mother! Guardians name:__________________________________________________ Employer:Home #: Work #:______________________________Cell 4: Other 4: -E-Mail Address: Street Address:C Father! Guardians name:__________________________________________________ Employer:Home 4: Work 4: - Cell 4: Other 4:E-Mail Address: Street Address:

    Emergency Contacts/Authorized Pick-ups:Individuals listed below can ac t as emergency contacts (if guardians cannot be reached) and are allowed to pick your ch ild up from programs until a written request ismade to remove a name. If, after registration, you would like to add additional names to the Emergency Contacts/Pick-up List, please send a written and signed request.1. Name: Relationship to Child:

    Number:2. Name: Relationship to Child: -

    Number:3. Name: Relationship to Child: -

    Number:4. Name: Relationship to Child: -

    Morrisville Parks, Recreation& Cultura l Resources

    Home Number:

    Home Number:

    Home Number:

    Other Number:

    Other Number:

    Other Number:

    Home Number: Cpu Nmher Other Number:

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    Cedar Fork Community Center Summer Camp 2013 WorksheetChilds Name (Last, First):

    Please check the weeks of camp you wish to enrol l your child in. Slide into the School Year Days are available asindividual Add-On Days August 12- 16 for Rising K- Rising 9th. Full payment is due at t ime of registration for SlideInto School Year Days and other Add-On Programs such as Dance Party and Camp-In.

    Camp Wiggle Worms CCF JR Camp Cedar Fork CIT Middle School(Ages 3-5) (Rising Kindergarten) (Rising1t_ tIi grades) (Rising 9h grades)205300 205310 205320 205330

    (R)$145 (NR) $218(R)$145 (NR) $218(R)$145 (NR) $218

    I understand and agree with the registration informationabove:

    and payment information stated

    Parent or Guardians Signature DateOFFICE USE ONLY (See back for additional payments)

    Deposit Cash / Check / Credit Card Amount: Remaining Balance: Initials:

    Balance

    Credit Card # (last 4 digits):______________ Receipt #: Date:

    Cash? Check / Credit Card Amount: Remaining Balance: Initials:

    1: June 10-14*No camp on June10 for CCF & CIT (RI $62 (NR) $93

    3: June 24-282: June 17-21 (R) $62 (NR) $93

    (RI $62 (NR) $93j (R)$100 (NR) $150 E (R)$100 (NR) $150(R)$125 (NR) $188 (R)$125 (NR) $188

    (R)$125 (NR) $188 (R)$125 (NR) $1884 : Ju ly 1-5 (RI $50 (NR) $75 (R) $115 INR( $172 (R($100 (NR) $150 (R)$100 lNRl $150No camp on July 45: July 8-12 (R) $62 (NR) $93 (R)$145 (NR) $218 D (R($125 (NR) $188 E (R)$125 (NR) $1886: July 15-19 (R)$62 (NR) $93 (R($145 (NR) $218 (R)$125 (NR) $188 (R($125 (NR( $1887: July 22-26 (R) $62 (NR) $93 (R)$145 (NR) $218 (R)$125 (NR) $188 (R($125 (NR( $188

    8: Ju ly 29- August 2 (RI $62 (NR) $93 (R)$145 (NRI $218 (R($125 (NR( $188 (R)$125 (NR) $1889: August 5-9 (R) $62 (NR( $93 (RI$145 (NR) $218 (Rl$125 (NRI $188 E (Rl$125 (NR) $188

    August12 (205210-Oil (RI $33 (NR) $50August 13 (205210-02) (R) $33 (NR) $50August 14(205210-03) (R) $33 (NR) $50August15 (205210-041 (R) $33 (NR) $50August16 (205210-05) (RI $33 (NR) $50

    CCF Dance Party (205150-01) (R($10 (NR) ss (R)$10 (NR) $15Fri. Aug. 2, 6pm-lOpmovernight Camp-In (205150-02) ri (Rl$40 (NR) $60July 12- 13, 8pm- 8amTotal Due

    Add upfeesfor all weeks of camp and addan days that are selected. This amount is due whenregistering on or after May17, 2013.

    Deposit DueII of Camp sessions x $25 (Only if registering before May 17, 2013) + Add On Programs

    BalanceSubtract Total Oue by the Oepasit Oue. This amount is due on or before May17, 2013.

    Check 1*:

    Check It: Credit Card It (last 4 digits):______________ Receipt U: Date:

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    Additional PaymentsCash / Check / Credit Card Amount: Remaining Balance: Initials:Check #: Credit Card # (last 4 digits):______________ Receipt #: Date:Additional PaymentsCash/Check! Credit Card Amount: Remaining Balance: Initials:Check #: Credit Card # (last 4 digits):_______________ Receipt #: Date:Additional PaymentsCash! Check / Credit Card Amount: Remaining Balance: Initials:Check #: Credit Card t (last 4 digits):______________ Receipt t: Date:Additional PaymentsCash / Check! Credit Card Amount: Remaining Balance: Initials:Check #: Credit Card U (last 4 digits):_______________ Receipt U: Date: