The Recreation Camp Application

2008

Open Registration at Camp

May 17^th @ 5:00pm or June 9^th @ 8:00am

 

550 Roosevelt Dr. [Rt. 34] Derby

 

 

 

 

Please Indicate:    Session I $300 ___    Session II $300 ___      Session I + II $500 [Save $100.00 !!!] ___

 

Name______________________________________ Birth Date ______Age [on 7/1] ___

Address _________________________________________________________________

City _________________________________________________Zip Code ___________

Home Phone # ____________________Parent’s Daytime Work Phone #1 _____________

Cell Phone # _____________or ____________ Parent’s Daytime Work Phone #2 _______

 

Emergency Information

Please provide us with the name(s) and phone number(s) of someone we may contact in case of emergency.

 

Name____________________________________________ Phone #_______________

Relation to Applicant _____________________________________________________ Name____________________________________________ Phone #_______________

Relation to Applicant _____________________________________________________

            

Medical Information

Use the following lines to list any pertinent medical problem(s) that would affect your son/daughter’s participation in the programs offered at Camp.  __________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 

Signature of Parent / Guardian ________________________________________

 

Discipline / Behavior Policy

 

Inappropriate behavior shall be defined as, but not limited to: disruptive behavior, disobedience / insubordination, actions which jeopardize

the safety of staff and/or other campers during supervised activities, and fighting or bullying. Upon the 1^st offense the ‘unruly’ camper shall

be verbally warned, upon the 2^nd offense the ‘unruly’ camper shall be asked to sit out that day’s activities [parent will be called] and upon

3^rd offense the ‘unruly’ camper shall receive a 1 day out-of-camp suspension. Any further unruliness may result in expulsion from camp

and forfeiture of part/all camp fee(s).

 

Signature of Parent / Guardian ______________________________________