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1 Flint Park Day Camp Application Camp Dates: July 6 th August 14 th In order for application to be accepted: 1. Application must be completed in its entirety. Immunization Records must be printed on the application. Insurance information must be on the application. Application must be signed. 2. Permission Form must be completed and signed. 3. Consent to Photograph must be completed and signed. 4. Campers Code of Conduct must be signed. 5. Fee must be attached. Checks should be made payable to the Village of Larchmont. $600 (1 st Graders only) 9:00AM 1:00PM After May 1, $650 (if space permitting) $875 (1 st 6 th Graders) 9:00AM 3:00PM After May 1, $925 (if space permitting) There will be no refunds.

2 VILLAGE OF LARCHMONT RECREATION DEPARTMENT FLINT PARK CAMP REGISTRATION 2015 THIS INFORMATION IS REQUIRED BY LAW AND ADMISSION TO CAMP CAN BE DENIED WITHOUT IT. YOUR CHILD S REGISTRATION WILL NOT BE ACCEPTED UNTIL THIS FORM IS COMPLETED IN ITS ENTIRETY AND SUBMITTED WITH APPROPRIATE FEE. PLEASE PRINT CLEARLY NAME OF CAMPER SEX M F AGE DATE OF BIRTH GRADE (IN FALL) SCHOOL HOME PHONE # GRADE 1 ONLY: HALF DAY FULL DAY HOME ADDRESS PARENT/GUARDIAN PARENT/GUARDIAN NAME WORK # CELL PHONE # PARENT/GUARDIAN NAME WORK # CELL PHONE # EMERGENCY NAME PHONE # CELL PHONE # EMERGENCY NAME PHONE # CELL PHONE # DOCTOR S LAST NAME PHONE # FRIEND OF CAMPER (MUST BE SAME GENDER/SAME GRADE) IMMUNIZATION RECORD/MEDICAL HISTORY PLEASE LIST EXACT DATES ON FORM (NO ATTACHMENTS PLEASE) 1. Diphtheria & Tetanus (DTap/DTP) Dates:,,,, 2. Polio (IPV/OPV) Dates:,, 3. Measles, Mumps & Rubella (MMR) Dates:, 4. Hepatitis B Dates:,, 5. Varicella (Chickenpox) Dates: or date of disease 6. Haemophilus Influenza (Hib) Dates:,,, 7. Pneumococcal Conjugate (PCV) Dates:,,, 8. Tetanus & Diphtheria (Tdap) (Grade 6) Dates: PLEASE LIST ANY MEDICAL CONCERNS OR RESTRICTIONS THAT WILL ASSIST OUR STAFF IN PROPERLY CARING FOR YOUR CHILD (ALLERGIES, MEDICAL PROBLEMS, SPECIAL DIET, AND RESTRICTIONS ON ACTIVITIES): WILL YOUR CHILD REQUIRE ANY MEDICATION TO BE HELD AT CAMP FOR THEIR MEDICAL NEEDS? YES NO IF YES, A SEPARATE MEDICAL AUTHORIZATION MUST BE COMPLETED BY THE PARENT AND PHYSICIAN (FORM WILL BE ED) AND RETURNED TO THE RECREATION DEPARTMENT BEFORE CAMP BEGINS. I GIVE PERMISSION, IN CASE OF INJURY, TO TAKE MY CHILD TO A HOSPITAL FOR TREATMENT, TO INCLUDE EVALUATION OF INJURIES, X-RAYS AND NEEDED CARE: PARENT/GUARDIAN S SIGNATURE DATE: HOSPITALIZATION INSURANCE CO. IDENTIFICATION #

3 Flint Park Day Camp 2015 Camper Name Grade (in fall) Parent/Guardian Name All sections on form must be completed. Authorization for Medical Treatment I hereby authorize staff certified in Standard First Aid or CPR at Flint Park Day Camp to provide emergency care for my child. Additional Comments: Parent/Guardian Signature Date ****************************************************** Permission to Swim at Hommocks Pool I hereby authorize that my child will be able to swim at Hommocks Pool. Parent/Guardian Signature Date ****************************************************** Arrival & Dismissal Procedures My child has permission to walk to and from camp. My child has permission to ride a bike to and from camp. Yes No Yes No The following people (other than parent) have permission to pick up my child from camp. Please print. Parent/Guardian Signature Date

4 Village of Larchmont Flint Park Day Camp Consent to Photograph / Film / Videotape Consent to Disseminate I, the undersigned, as the parent or legal guardian of the child named below, grant permission to the Village of Larchmont, its officers, agents, employees, and volunteers (collectively, the Village ), to take photographs, motion pictures, audio and/or videotape my child and/or me and during Flint Park Day Camp activities. I also grant permission to the Village to share these photographs and recordings via with other parents and legal guardians of children enrolled in Flint Park Day Camp for the 2015 camp season. I waive any right to compensation or monetary damages with respect to such use by the Village of my or my child s name, likeness, picture and/or voice including without limitation any claim for invasion of privacy, and I release the Village from all claims, demands, and liabilities whatsoever in connection with this Consent. I have read and understand the terms of this Consent. (Check one:) Parent: Legal guardian: Parent / Legal Guardian s Name: Parent / Legal Guardian s Signature: Date: Child s Name:

5 Summer 2015 Dear Parents: Every year when we welcome campers to Flint Park Day Camp, our expectations in terms of conduct and group participation are high. To best ensure an environment that is safe and fun, we again offer this camper and counselor code of conduct for family discussion. The following are guidelines for campers that we believe will set the general tone of cooperation and respect. We encourage you to review these principals with your camper. We view this as a wonderful opportunity to facilitate a successful camp season for all. We thank you for your participation in this matter. A signed copy of this form must to be returned with your camp application: Camper Code of Conduct Camper agrees to follow the rules set forth by Flint Park Day Camp. Camper will not wander from his/her group. Camper agrees to participate in all games. Camper will obey the rules and procedures when we go on off-site field trips. Camper agrees to clean up after him/herself after my snack and lunch. Camper will not litter. Camper pledges to keep safety as a priority when participating in water activities. CAMPER AGREES TO REFRAIN FROM USING INAPPROPRIATE LANGUAGE AND TO NOT ENGAGE IN ANY PUT- DOWNS TOWARDS OTHER CAMPERS. CAMPERS WILL NOT BULLY OTHER CAMPERS. Joyce Callahan Recreation Director Please Print Camper s Name Parent s Signature

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