2023 Summer Playground Program Registration
Fill out a separate registration for each child.  The Summer Playground Program will be offered free to children ages 5 to 12 living in Robesonia Borough or Heidelberg Township, June 12 through July 28, Monday through Friday, from 9 AM to 12 PM.
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Child's Name *
Age of child on June 12, 2023 *
Address *
City *
Required
Parent / Guardian 1 Name *
Parent / Guardian 1 Phone *
Parent / Guardian 2 Name
Parent / Guardian 2 Phone
Preferred email address *
Emergency Contact Name and Phone (if Parents / Guardians cannot be reached) *
Please check one: *
Person(s) authorized to pick up child
MEDICAL HISTORY
Please list any medical problems, allergies, and/or medications your child is currently taking.  Please be specific.
Family Doctor
Family Doctor Phone
Does your child have an allergic reaction to bee or wasp stings? *
If yes, indicate any reaction:
Is your child covered by health / medical insurance?
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RELEASE AND WAIVER OF LIABILITY.  
The undersigned gives permission for their child to attend and participate in the 2023 Summer Playground Program (“Program”) sponsored by the Robesonia Parks and Recreation Board.  
(1) I/we are the legal parent(s) and/or legal custodian(s) of the minor child/children listed above and have full power and authority to execute this Release and Waiver of Liability on behalf of such minor child/children. 
(2) The Program and its activities may involve certain risks, including but not limited to using any playground areas, property, equipment or apparatus (“Facilities”), that may result in bodily injury, emotional injury, personal injury, accident, injury, illness, death, property damage and/or loss. 
(3) All participants shall comply with any and all federal, state and local regulations, laws, guidelines, rules, and orders including guidelines issued by the United States Centers for Disease Control regarding actions to be taken to prevent the spread of COVID-19 or other disease. 
(4) I/we, in my/our own right and/or on behalf of my/our minor child/children listed above, and our heirs, representatives, agents and assigns (collectively, the “Releasors”), in consideration for participation in the Program and the Facilities, or any of them, hereby jointly and severally RELEASE, INDEMNIFY, SAVE, HOLD HARMLESS, WAIVE, FOREVER DISCHARGE and DEFEND the Borough, its Council, its Mayor, officers, employees, committee/board members, licensees, contractors, agents, attorneys, engineers, representatives, related organizations and members, successors and assigns (collectively, the “Released Parties”) against any and all damages, claims, liabilities, demands, actions, causes of action and suits of every kind and nature which the Releasors, or any of them, may have, or may in the future have, against the Released Parties for any bodily injury, emotional injury, personal injury, accident, injury, illness, death, property damage or loss resulting from any circumstances including but not limited to COVID-19, which the Releasors, or any of them, may sustain while participating in the Program, or in any activities, programs and/or trips associated with the Program, and/or use of the Facilities, including but not limited to any and all claims which arise on account of any first aid, treatment or service rendered in connection with the Program and/or use of the Facilities or which result from negligence on the part of the Released Parties, or any of them. 
(5) Except as otherwise agreed to by the Released Parties in writing, the Released Parties do not carry or maintain insurance coverage for the Releasors, or any of them. Each Releasor is expected and encouraged to obtain his or her own insurance coverages. 
(6) To the extent that the Program involves the use of private motor vehicles and/or the use of parking lots at the Facilities, the Released Parties shall bear no responsibility to the Releasors for the maintenance, operation, use, security or insurance of such vehicles or any accidents resulting from the use of such vehicles. 
(7) This Release and Waiver of Liability is intended to be as broad and inclusive as permitted by the laws of the Commonwealth of Pennsylvania. 
(8) This Release and Waiver of Liability shall be governed by and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. 
(9) In the event any clause, sentence or provision of this Release and Waiver of Liability shall be held to be invalid or unenforceable by any court of competent jurisdiction, the validity of such clause, sentence or provision shall not otherwise affect the remaining clauses, sentences and provisions of this Release and Waiver of Liability, which shall continue to be valid and enforceable.
Required
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Email confirmation of registration will be sent upon review and acceptance of the application.
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