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Registration Packet
Registration Packet
Date Paid:_______________
Date Entered:____________
By Whom:______________
F Grade ______
Parent(s) Name(s)____________________________________________________________________________________________
Mailing Address: PO Box/Street____________________________________Town_________________State______Zip__________
Residence:Street & Number_______________________________________Town_________________State______Zip__________
Home Phone:___________________________Work Phone:___________________________Email:_________________________
Emergency Contact Name:________________________________________Emergency Contact Phone #____________________
List all allergies or physical difficulties that the Staff should be aware of: _____________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Waiver Agreement:
I am fully aware that there are risks of physical injury in participating in sports and recreational
activities and hereby give my consent for the named applicant to participate in the program(s) offered by Stowe Parks and
Recreation. I hereby knowingly and fully release and hold harmless the Town of Stowe, its employees, elected officials, any
volunteers, instructors or sub- contractors from any and all liability from injury claims, costs, loss of services, damages or loss
of personal property in the said programs, activities or events. I certify that my child/participant is in excellent health and that
there are no limitations to his/her participation except as stated in writing above. Furthermore, in the event of an emergency,
accident, injury, or illness and if reasonable effort to contact me has failed, I hereby give the designated emergency contact
permission to act as my childs(rens) temporary guardian. In the event of an accident, injury, or illness and if reasonable effort
to contact me has failed, I hereby give attending physicians or authorized medical personnel consent and permission to provide
my child/participant with any necessary medical treatment, including x-rays and medication.
_________________________________________________________
Parent or Legal Guardian Signature/Date
Photo Permission:
From time to time photographs will be taken to be used in our publications. Do you give the Stowe Parks and Recreation
Department permission to use yours and/or your childs photograph?
YES
NO
Program Name
____ Visa
____ MasterCard
Credit Card*
Debit Card
Fee
TOTAL
____ Discover
#__________________________________ Exp Date __________ 3-digit Security Code (on back of card)____________
*The Town of Stowe is authorized to a 3% convenience charge for the use of credit cards
One form per child must be filled out by a parent or guardian and returned to the Recreation Office.
Childs Name: _________________________________
Authorized to Pick Up:
NAME
1.___________________________
2.___________________________
3.___________________________
RELATIONSHIP
_________________________
_________________________
_________________________
Non-Swimmer
Beginner
PHONE #
__________________
__________________
__________________
Intermediate
Advanced
Yes
No
(This must be someone other than the parents, and will be used if neither parent can be reached)
Relationship: ____________________________
Address: __________________________________________________________________________________________
(Street Address)
(City)
(State)
(Zip)
Health History:
Medication: Please list the medications that your child is required to take daily: ____________________________
1.) Will any of these medications need to be administered to your child during camp?
Yes
No
(If yes, you must fill out the Medication Authorization Form, and bring to camp on the first day with medication)
Allergies:
2.) Is your child required to carry an epinephrine pen with them at all times?
Yes
No
1.) Does your child have any allergies to food, medication or the environment?
Yes
No
(If yes, please describe in detail the allergies, reaction and the management or care needed)
Allergies
_____________________________
_____________________________
Medical Conditions:
Reaction
_______________________
_______________________
1.) Does your child have any Medical Conditions that we need to be aware of?
Yes
No
(If yes, please describe in detail the condition, symptoms, and the management or care needed)
Medical Condition
______________________________
______________________________
Symptoms
________________________
________________________
Sunscreen/Insect Repellent:
____YES- I give permission for the Stowe Parks & Recreation staff/employees to apply sunscreen and/or insect repellant to my
child, for the 2015 summer season.
____ NO - I do not give permission for sunscreen or insect repellent to be applied to my child. We will do it at home.
Please provide any additional information about your childs behavior, and/or physical,
emotional or mental health concerns that the camp staff should be aware of: ___________________________________
________________________________________________________________________________________________
Additional Information:
I attest the information above is correct and complete to the best of my knowledge. I hereby agree to the release of any information for the
knowledge of Stowe Parks & Recreation staff, necessary treatment, and give my child the proper medication and/or grant them the permissions as
stated.
Signature of Parent/Guardian _________________________________________________
Date: ________________________________
Camp Directors will NOT give medication to any child until this form is completed and returned to them or the Recreation Office.
Please carefully read the instructions below. If these procedures are not followed we will not be able to administer any medication
to your child.
Prescribed Medication:
1.
2.
3.
We must receive any prescribed medication in its original packaging and/or bottle with your childs name on it.
It must identify the prescribing physician, the name of the medication, the dosage, and the frequency of administration.
All information on the bottle must also match the information you fill out on the Medication Authorization Form. Place
this form and medication in a zip lock bag and give to the Camp Director .
Non-Prescribed Medication:
1.
2.
Medication:
Medication #1 __________________________________________ Dosage _________________________________
Times to be administered: __________________________
Refrigerate:
Yes____ No _____
Side Effects ________________________________________________________________________________
Stop Medication if the following reactions occur: __________________________________________________
Medication #2 __________________________________________ Dosage _________________________________
Times to be administered: __________________________
Refrigerate:
Yes____ No _____
Side Effects ________________________________________________________________________________
Stop Medication if the following reactions occur: __________________________________________________
Medication #3 __________________________________________ Dosage _________________________________
Times to be administered: __________________________
Refrigerate:
Yes____ No _____
Side Effects ________________________________________________________________________________
Stop Medication if the following reactions occur: __________________________________________________
Medication Log
Campers Name: ______________________________________
Consent: I hereby give permission for my child to take the below listed prescription or non-prescription medication(s), as ordered, at the Stowe Parks
& Recreation Summer Camp, I give permission for this medication to be administered by the Camp Director or his/her designee.
Date: _________________________
This Section is to be filled out by the camp director each day that medication is administered:
Name of Medication
Dosage
1.
2.
3.
TUES
WED
THURS
FRI
PO Box 730
336 Park Street
Stowe, VT 05672
______________________________
Parent/Guardian Signature
Email: Recreation@townofstowevermont.org
___________________________
Childs Signature