Camp Hofstra

Grade during 2022 *

1 2 3 4 5 6 7 8

Child’s Name:

DOB:

Date

Current Age:

T-Shirt Size:

S M L XL

Mailing Address:

Street Address

Street Address Line 2

Town

Postal / Zip Code

Mother’s name:

Phone #:

Email

example@example.com

Father's name

Phone #:

Email

example@example.com

Other Emergency Contact Name:

Phone #:

Child may leave without a parent at any time:

or child must be picked up:

If child is picked up after program, due to illness or early dismissal: please name the person(s) with permission to pick up other than parents:

Name:

Telephone #:

Relationship to child:

Name:

Telephone #:

Relationship to child:

PLEASE MARK THE WEEKS YOUR CHILD WILL BE ATTENDING

	Please Mark the Weeks	Cost - REGULAR SESSION $100.00/WEEK/CHILD	Cost - CHILD EXTENED SESSION $120.00 /WEEK/CHILD
JUNE 28TH- JULY 1ST
JULY 4TH –JULY 8TH***
JULY 11TH- JULY 15TH
JULY 18TH - JULY 22ND
JULY 25TH- JULY 29TH
AUG 1ST- AUG 5TH
AUG 8TH - AUG 12TH
AUG 15TH- AUG 19TH
AUG 22ND - AUG 26TH
AUG 29TH – SEP 2ND

*** Please be advised the week of July 1st is a short week due to 4th of July. Camp fees for that week are $80.00 regular session and $100.00 Extended Session

Special Savings

Full 10 week Session Paid in Full receives a 10% discount

Session #1 (first 5 weeks of camp) Paid in Full receives a 5% discount

Session #2 (last 5 weeks of camp) Paid in Full receives a 5% discount

Total Amount Enclosed: $

*Extended Day is purchased for the entire week. No daily payments permitted.

Extra field trips added to the program may require additional payment.

All registration payments must be completed in advance of attendance and must be processed at the Recreation Office in the Municipal Building at 106 Brown Avenue. Registrations and payments are accepted Monday-Friday 8:30 AM-4:30 PM. Registrations and payments will not be accepted at the camp site by camp supervisory staff.

Camp Registration fees are non-refundable. Absolutely no refunds will be made in the event of a cancellation other than for a valid medical reason as certified by the camper’s licensed physician submitted to the Recreation Director in Written form on the physician’s letterhead. All medical refunds are subject to a 50% charge of the unused portion of the registration fee. Any camper dismissed from camp for disciplinary reasons will not be eligible for a refund of any unused portion of their registration fees.

Parent’s permission for Hospital or Doctor to administer anesthetic and or emergency treatment if required?

Yes No

By enrolling and signing this application, I give my child permission to attend any field trips or activities. I authorize any medical treatment in my absence for the well-being of my child and in case of an emergency. I have listed above any special, medical, physical and allergies that the staff should be aware of. I understand that if my child requires an inhaler/epi-pen that my child is responsible for taking it with him/her on any trip or activity and any accidents or injuries will be reported to the Recreation office as soon as possible for me to be contacted.

The applicant, parents, guardians or family members, to the fullest extent permitted by law, hereby agrees to indemnify and or hold harmless the Borough of Prospect Oar and all if its agents, directors, officers, employees and volunteers and the physician or hospital treating my child against any and all claims, judgments, demands for damages and expenses, including but not limited to attorneys fees, arising out of by reason of, on account of, in consequence of, or in connection with my child’s participation in the program or other participants or any other person (s) to which this application applies.

Parents will be responsible for the conduct of their child while participating on the program and enforce all rules and regulations as required by the Borough Recreation Program. Parent agrees and acknowledges that any violations to the rules and regulations will not be subjected to expulsion from the Summer Camp program and any other Borough’s sponsored program.

Parent/Guardian

Date:

Date

Health History

The information you provide here will be held in the strictest confidence. It will be kept on file in our program health binder or carried by the director or counselor when your child travels with one of our groups. This information will be shared with other key recreation staff only on a “need-to-know” basis. Because this is our first resource in the event of an emergency, it is important that you be as specific as possible.

Child’s Doctor’s Name:

Address:

Doctor’s Phone

Medical Insurance Information: Company Poly #

Exp. Date:

Date

Policy Holder’s Name:

First Name Last Name

Allergies & Medical Conditions

Yes No

Please describe the severity of the reaction, requested accommodations and what is done to manage them.

You may serve my child food and beverages:

Yes No

Medical, Physical or Emotional Conditions (including disabilities) that may affect his/her experience at our program.

Yes No

Please provide information to assist us in providing the best camp experience for your child.

Medications (including inhalers)

Yes No If your child must take medication while at camp, please note that here. All medications must be in their original containers and be appropriately labeled. We must have a MEDICATION FORM detailing the medications, doses, and administration instruction for all prescription medications. Please do not give the counselors your child’s medication for them to bring to the camp; medications must be received and held by the recreation office.

Immunizations

Is your child up-to-date on all State-required immunizations?

Yes No

Please explain:

What have we forgotten to ask? (For example, does your child have any reactions or special instructions for sunscreen use?) Please provide any other information about your child’s health, which has not been asked on this form.

Parent/Guardian Consent and Waiver

I hereby represent that the above information is true and accurate and the named applicant is in good health and has my permission to participate in Camp Hofstra 2020, knowing that the camp will be on an open field, I HEREBY WAIVE AND RELEASE Prospect Park Recreation Department, its agents, counselors, trainers and directors from any and all liability and claims for damages. In the event of an emergency, I hereby give permission to such medical personnel as necessary to render treatment.

Parent/Guardian Signature

Date:

Date

PROSPECT PARK RECREATION DEPARTMENT CAMP HOFSTRA REGISTRATION