Registration Form-Hellertown Parks Program At Water St Park Session 1

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90 W Water St, Hellertown, PA 18055

June 17th-July 12th

Monday thru Friday

9am-12pm

Child's Name *

Child's Date of Birth *

YYYY

Grade Completed *

Please select the grade your child will have completed at the end of the 2023/2024 school year. Must have completed kindergarten to attend the parks program.

Parent/Guardian *

Full Address *

Please include Street, City, and Zip Code

Home Phone *

Work Phone *

Email *

Additional contact in the event you cannot be reached. *

Please provide 2 contacts and write the full name, phone, and address.

Medical Information: Allergies (medical, food, bees, etc.) *

Write N/A if child does not have any medications or allergies. STAFF IS NOT PERMITTED TO ADMINISTER MEDICATION.

Medical Information: Other *

Write N/A if child does not have any other pertinent medical information. STAFF IS NOT PERMITTED TO ADMINISTER MEDICATION.

Medical Information: Asthma *

STAFF IS NOT PERMITTED TO ADMINISTER MEDICATION.

Yes

Medical Information: Inhaler *

STAFF IS NOT PERMITTED TO ADMINISTER MEDICATION.

Yes

Medical Information: Limitations *

Write N/A if your child has no limitations. STAFF IS NOT PERMITTED TO ADMINISTER MEDICATION.

I will send my child to the parks program every day with sunblock already applied. *

Please initial to show that your child will be arriving every day with sunblock already applied.

Are there any special accommodations needed for your child to participate in the program? *

Write N/A if child doesn't not require and special accommodations. STAFF IS NOT PERMITTED TO ADMINISTER MEDICATION.

I will bring and pick up my child every day. If I am unable to be there, my child has permission to be transported by: *

Please write the name of a second person who is permitted to transport your child to and from the program and then initial. If you child will be arriving and/or departing in another manner, please write N/A and proceed to the next question.

There will be no adult dropping off or picking up my child. His/Her means of arrival and departure will be: *

Please write the method in which your child will be arriving and departing and initial. If you will be dropping off and picking up your child, please write N/A and proceed to the next question.

I will drop off my child, but am not able to pick him/her up, they are instructed to: *

Please write the method in which your child will be departing and initial. If you will be dropping off and picking up your child, please write N/A and proceed to the next question.

I agree to pay $10 for the first child I enroll and $5 for each additional child. *

Please initial

My child will be participating in the Saucon Valley Community Center Summer Children's Program. In the event that my above choice in some way leaves my child unsupervised before or after Summer Children's Program, I understand the Center will in no way be responsible. If my child arrives and departs on their own, and he/she needs to leave the programs before scheduled ending time, I understand that I must notify personally or in writing, the program with an adult that is not specified in the arrival/departure procedures. I will assume all risks and hazard incidental to participate in the above mentioned activity. I hereby waive, release, indemnify, absolve, and agree to hold harmless the Saucon Valley Community Center, it's officers, staff employees, agents, and participants for any claim whatsoever arising out of injury to my child and all claims regarding to personal property. I have read, understand, and will adhere to the rules set forth in the Saucon Valley Community Center Rules and Regulations.

Please leave this section blank. We will have your completed form printed out for you to sign when you come in to make your payment.

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