Summer Day Camp Application
Please fill out the following information accurately. Withholding information may result in your child being expelled from the camp. It is of absolute necessity that the Parks & Recreation supervisory staff have all information on your child/children, including medical information, to provide a safe camp setting for everyone. Your child's information will be kept confidential.

Program & Registration Refund Policy: All program registration fees must be paid prior to the start of the program. All registrants are entitled to a full refund in the event of cancellation, or until the first day the program begins. Late entry into, withdrawal from or limited attendance in a program will not entitle any individual to a refund. The Parks and Recreation Board and/or Department reserve the right to deny entry into, or remove any participant from any program due to disciplinary problems or to avoid creating a staffing hardship situation which is beyond reasonable expectations of the Town of Liberty Parks & Recreation Department. All refunds under this policy will be made through the Town of Liberty's monthly voucher system.

Release of Liability and Assumption of Risk Agreement: In reference to the registrant(s), I agree to the unreserved use of my name and/or likeness (including photographs, videotapes and other depiction) FOR PUBLICIZING the Town of Liberty Parks and Recreation Department activities. In CONSIDERATION of the acceptance of the application for entry into the classes or activities listed above, I hereby WAIVE, RELEASE, and DISCHARGE any and all claims for damages for death, personal injury, or property damage which I may have, or which may hereafter accrue to me as a result of my participation in said classes or activities. This release is intended to discharge in advance the Town of Liberty, the Town Board members, its officers, agents and employees from and against any and all liability arising out of or connected with my participation in said classes or activities. I am aware that these classes or activities subject me to physical risks and dangers. Nevertheless, I voluntarily agree to assume any and all risks of injury or death, and to release, discharge and hold harmless all of the entities or persons mentioned above. It is understood and agreed that this waiver, release, and assumption of risk is to be binding on my heirs, personal representatives, next of kin, spouse and assigns.

The submission of this application gives the named individual(s) permission to participate in the above designated program(s) and the information provided is accurate to the best of my knowledge.
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Email *
Camper's Name *
Date of Birth *
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DD
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YYYY
Age at Start of Camp *
Current Grade *
Gender *
Resident or Non-Resident *
Session *
Parent/Guardian #1 Full Name *
Please include home, cell, and work phone number.
Parent/Guardian #1 Address *
Parent/Guardian #2 Full Name *
Please include home, cell, and work phone number.
Parent/Guardian #2 Address (if different than listed above)
In case we cannot reach Parents/Guardians, please contact #1: *
Please include name & numbers (home, cell, and work).
In case we cannot reach Parents/Guardians, please contact #2: *
Please include name & numbers (home, cell, and work).
Pick Up List *
Be sure to list all possible persons, including yourself, that may pick up your child. Their name must appear here or your child will not be erased to them. Persons must be at least 18 years of age. Photo ID must be present.
As the above named child's parent/guardian, I give the Town of Liberty Parks & Recreation Day Camp permission to have my child receive emergency medical treatment in the event it is necessary and I cannot be reached. *
As the above named child's parent/guardian, I give the Town of Liberty Parks & Recreation Day Camp permission to have my child swim at the Hanofee park swimming pool. Certified Lifeguards and Counselors are present. *
As the above named child's parent/guardian, I give the Town of Liberty Parks & Recreation Day Camp permission to have my child allow the Day Camp Staff to assist my child with applying sunscreen to his or her exposed skin including but not limited to the face, ears, nose, neck, shoulders, arms, and legs. *
**Please fill out the following information accurately. Withholding information may result in your child being expelled from the camp. It is of absolute necessity that the Parks & Recreation supervisory staff have all information on your child/children, including medical information, to provide a safe camp setting for everyone. Your child's information will be kept confidential.
Is your child subject to or have a history of allergies: *
Required
If you have checked any of the boxes above, please explain in full in the space provided.
Is your child subject to or have a history of medical: *
If you have checked any of the boxes above, please explain in full in the space provided.
Your child's hearing is: *
Your child's eyesight is: *
Your child's swimming ability is: *
Has your child recently been immunized for tetanus? *
Medications that must be administered by the Parent/Guardian at the following times: *
If marked yes above, please explain as best you can, including times.
Any and all treatments, surgeries, DR./ER. visits, or other medical concerns we should be aware of within the last six months: *
If marked yes above, please explain as best you can.
Child's Physician's Name and Phone Number *
You have now completed the general and health information portion of the application. The Camp Policies and Parent Contract is next!
In the areas below, please initial each item, showing that the following agreement has been read and is understood.
I am aware that the Day Camp hours are from 8:00 am until 5:00 pm. Your child is expected to be dropped off no earlier than 8:00 am and picked up no later than 5:00 pm. Prior to registering your child, please make sure the necessary arrangements to allow this to occur. We realize that situations arise that might cause the driver to be late. If this does happen, it is the parent/guardian's responsibility to contact the Parks & Recreation office at (845) 292-7690 prior to 4:00 pm. This will give the camp staff enough time to arrange for a staff member to stay with your child. You will be charged the staff member's hourly rate of pay for the time that you are late. This will be due when you pick your child up. It is our goal to make your child's day as fun filled and stress free as possible. *
If I bring my child late to camp, I will take him/her directly to the camp director's office for check in so the child may be safely taken to their group. *
Breakfast and lunch will be available for your child. If your child does not want that, then you must provide a proper lunch for your child daily (drink, sandwich, snack) or provide money for your child to purchase his/her lunch at the concession stand. I will also provide my child with a  water bottle to use throughout the day. *
I will ensure that my child is dressed appropriately for the program(s) and weather: Sneakers, shorts or pants, t-shirt, swim suit, and towel, sweater/sweatshirt, hat, sunscreen and insect repellent, and long sleeved tops and pants for hiking activities. *
NO OPENED TOED SHOES! Children will not be able to participate in any activities and will be sent home if they do not have closed toed shoes! *
I will send my child with sunscreen of SPF 50 or higher with his/her name printed on the bottle and I will send my child with sunscreen applied before drop off. *
I will ensure my child follows directions of camp staff for their safety, enjoyment, and smooth operation of the program. I am aware that inappropriate behaviors will not be tolerated. A child exhibiting behaviors of: VIOLENCE, SEXUAL HARASSMENT, ENDANGERING THE SAFETY OF A CAMPER OR STAFF MEMBER, ANY TYPE OF DISCRIMINATION, THEFT, VERBAL ABUSE, AND POSSESSION OF ANY WEAPON OR FIRE STARTERS (matches/lighters) will result in immediate suspension of the child from camp. The child's parents will be called to pick up the child immediately. At the end of the camp day, the incident will be reviewed by administrative staff and determination on the child's continued attendance in the program will be made. Parents will be notified of the results of the review. Incidents will be handled on a case by case basis. *
I will become familiar with the camp schedule to ensure my child has all items needed for each day. *
I will label my child's belongings in case they are misplaced and I will check my child's belongings each day before we leave camp to make sure everything is accounted for. The Town of Liberty and/or staff are not responsible for any lost or stolen items. *
All electronic devices including cell phones are prohibited unless permission is granted by the Camp Director on rainy days. Games such as Magic Cards are not recommended to send with your child to camp. The Town of Liberty and/or staff are not responsible for any lost or stolen items. *
I will take time to talk to my child's counselor to evaluate the program as it relates to him/her. *
I will ensure that my child's medical records are completed accurately and in full for the safety of my child. Registration is not complete until this information is in the office. *
I will ensure that any changes in my child's medical records/emergency phone numbers will be updated immediately to ensure the safety of my child. I also understand that int he case of a serious emergency, 911 will be contacted first, and then the emergency number listed on my child's registration form will be called. *
I understand that the Town's Day Camp is not a therapeutic environment and cannot provide the setting for youngsters requiring any extensive therapeutic support or educational disabilities. However, the Parks and Recreation Administration reserve the right to call in any professional, be it medical or mental health, for consultation as they see fit. *
Parents are responsible for administering any medication required by your child or your child must be able to self-direct medication. Our staff are not qualified nor allowed to administer medication. *
Head Lice: Camp has a no nit policy. In the unfortunate event your child is found to have head lice your child will not be permitted to return to camp until they are nit free. *
Camp my have to close due to extreme weather and/or unforeseen circumstances. If this does occur, camp could be closed for the entire day or camp may have to close early and your child will need to be picked up. Please have a plan in place for someone on the pick-up list to get your child and a place your child can go. *
I understand that if my child is expelled from camp, there will not be a refund of camp fees. *
I understand the Town of Liberty Parks & Recreation Site Security Administrator will access my child's immunization records in the event immunization records are not provided at the time of registration. *
I, the parent/guardian of the camper listed above, have read and agree to the policies and will follow the mandatory responsibilities listed in the Day Camp Policies/Parent Contract. *
Please sign with full name and date.
Payment
Please mail a check payable to Town of Liberty Parks & Recreation to 119 North Main Street, Liberty, NY 12754.
Application will be finalized when a payment has been received.
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