Playground Camp 2023
*Summer Camp Enrollment is not guaranteed until payment is arranged and this form is summitted.  
*Trips are an additional fee. If your child does not attend the field trip, there is no camp that day.
*There are no refunds for summer camp. 
*Use one form per child
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Child's First Name *
Child's Last Name *
Child's Birthday *
Child's Age *
Child's Home Address *
Child's School *
Child's Grade 2023/2024  *
Parent/Guardian #1 NAME *
Parent/Guardian #1 Address *
Parent/Guardian #1 Relationship to Child *
Parent/Guardian #1 Cell Phone Number *
Parent/Guardian #1 Work Phone Number
Parent/Guardian #1 Home Phone
Parent/Guardian #1 EMAIL *
Parent/Guardian #2 NAME *
Parent/Guardian #2 Relationship to Child *
Parent/Guardian #2 Cell Phone Number *
Parent/Guardian #2 Work Phone Number
Parent/Guardian #2 Email *
Parent/Guardian #2 Address
Parent/Guardian #3 Name
Additional Adult #3 Name 
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Additonial Adult #3 Cell Phone Number
Additional Authorized Pick Up Persons
Does Your Child Need A Lifejacket? *
Does the participant have any medical conditions? *
Required
Is participant on any medication(s)? *
Required
What kind of medication(s)?
Please state any other conditions or special needs the staff should be aware of.
I have read, understand and agree to the following:
-Camp & Parent Information
-Behavior Agreement
-Refund Policy
-Medication Dispensing Procedure
-Camper Illness and Preventative Measures
-App Alerts (messaging)
 *
Required
RELEASE OF LIABILITY-
I understand and agree, for myself and/or for any minors in my care, that participation in any activities and programs sponsored by Plymouth Township (the “Township”), where the Township provides facilities, instruction and/or supervision, could result in injury to myself, minors in my care and/or to personal property owned by me or such minors. In consideration for being permitted to use the Township’s facilities and/or participate in Township-sponsored activities/programs, I agree:
For myself and/or for any minors in my care, to fully and completely release the Township, its officials, employees, boards, departments, agents volunteers, representatives and affiliated entities from any and all claims, liabilities or actions for any personal injuries to me, personal injuries to minors in my care and/or any loss or damage to my personal property or the personal property of any such minors arising from our use of Township facilities or participation in Township-sponsored activities and programs.
 *
Required
I certify that to the best of my knowledge, I and/or any minors in my care are healthy enough to participate in the recreation program sponsored by the Township. I understand that no health and/or accident insurance are provided by the Township. I also understand and agree, for myself, and/or for any minors in my care, that I am solely responsible for the cost and expense for furnishing medical or other insurance to cover any expenses related to any such personal injuries or property damage.
 *
Required
I hereby give the Township’s staff permission to secure emergency medical care for minors in my care who may suffer an injury or illness while in the temporary care of Township representatives.
 *
Required
I agree, for myself and/or for any minors in my care, to comply with all Township rules and regulations, including any rules and regulations governing any activities or programs for which I, and/or any minors in my care, have registered, and understand and agree that noncompliance with any such rules and regulations by me, or any minors in my care, may result in termination of the privilege to use Township facilities and/or participate in Township-sponsored activities and programs. In the event of such a termination for cause, I under-stand that I will not be entitled to be reimbursed for any registration, activity or program fees.
 *
Required
I grant the Township the right to use my/our name, image, photograph and video, including composite or modification, representations in publications, brochures, newsletters, reports, website, social media, videos and any other material relating to Township activities. I waive the right to inspect or approve versions of my/our image used for publication or the written copy that may be used in connection with the image. If I do not wish to have my child’s photo/video published, I must submit a request in writing.
 *
Required
I have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability and a contract between myself and/or any minors in my care and the Township, and sign it of my own free will. Intending to be legally bound hereby, and with full authority, I acknowledge, agree to and accept the terms of this Liability Waiver and Release on behalf of myself and/or on behalf of any minors in my care.
 *
Required
I understand that the Township shall be excused from performance hereunder to the extent that such performance has been prevented by the consequences, direct or indirect, of labor troubles, fires, utility loss, accidents, war, terrorism, civil disobedience, and causes beyond the control of the Township.
 *
Required
I have read, understand and agree to all the above. 
Please type your Name and Date.
 *
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