Summer Camp 2023

Fairfax Summer Camp Registration
Please note that there is a $25 non-refundable deposit fee for each week registered due by April 7th, 2023 for all registrations.

Payment for each week of camp is due 2 weeks before the specified week begins. For both full payment and your deposit, we will reach out to you directly for payment information.

These camps run from 8AM to 5PM every weekday.

Please submit only one application form for each child you register. If there is an issue with the form you submitted, please contact Danielle at recreation@fairfax-vt.gov instead of submitting a duplicate form.
Child Information
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
What Grade is your Child entering in the fall of 2023?*
Child's Gender*

Prefer not to sayMaleFemaleOther
Please list all known allergies your child has*
Please list any dietary restrictions your child has*
Please list any medications your child takes*
Does your child require modifications to be made to the camp or accommodations to participate? If so, briefly describe and we will be in touch.
Week Selection

Select the weeks which you'd like to register your child for our day camp - if a certain week is listed as "[FULL]" we will add them to a waiting list for that week if selected. Each week of camp is $185, except the week of 4th of July which is $120. Please remember that a $25 non-refundable deposit is due for each week you select by April 7th (weeks you select that are already full will not require a deposit or commitment until we can add you to that week of camp)
Which weeks would you like to register your child for?*

Week 1 June 19th - 23rdWeek 2 June 26th - 30thWeek 3 (3 days only) July 5th - 8thWeek 4 July 10th - 14thWeek 5 July 17th - 21stWeek 6 July 24th - 28thWeek 7 July 31st - August 4thWeek 8 August 7th -11thWeek 9 August 14th - 18th
Contact Information
Primary Parent or Guardian Name*

First NameLast Name
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number*
Please enter a valid phone number.
Primary Email*
example@example.com
Primary Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact (Cannot be the same as Primary)*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contacts Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional person who has permission to pick up this child

First NameLast Name
Additional person's phone number
Please enter a valid phone number.
Permissions
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, INDEMNITY, AND PARENTAL CONSENT AGREEMENT

I hereby release and discharge the Town of Fairfax, it's agents, employees, staff members, directors, and volunteers from any claims, responsibilities or liabilities for injuries or harm incurred as a result of my child's involvement as a participant in summer camps through the Town of Fairfax.

I accept that allowing my child to participate in educational, instructional or recreation activities includes risks. These activities may be led or conducted by staff, contracted staff or others, and may include but are not limited to: Hiking, walking, and biking near rivers and over even or uneven terrain; Basic ropes or challenge course activities; Interactive games and other sporting activities; Swimming and wading in natural rivers; socializing; outdoor cooking or other chores; Use of any equipment, facilities or premises; and travel by foot.
Signature*

Clear
Date (Today's Date)*

MonthDayYear
Date
MEDICAL RELEASE

I hereby grant consent to any and all health care providers designated by the Town of Fairfax to provide my child with any necessary medical care as a result of any injury or illness. This consent includes First Aid and CPR administered by staff of the Town of Fairfax and transportation by Fairfax Rescue to the hospital.

If an emergency should arise, I understand that a thorough effort will be made to contact me or or an emergency contact before action is taken, but I agree to accept any expense associated with such an emergency if it is not possible to contact me in advance of treatment.
Signature*

Clear
Date (Today's Date)*

MonthDayYear
Date
ASSUMPTION OF THE RISK AND WAIVER OF LIABILITY RELATING TO COVID-19

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child and I may be exposed to or infected with COVID-19 by attending this camp and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at this camp may result from the actions, omissions, or negligence of myself and others, including, but not limited to, camp employees, volunteers, program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child or myself (including but not limited to, personal injury, disability and death) illness, damage, loss, claim, liability, or expense of any kind, that I or my child may experience or incur in connection with my child's attendance at the Town of Fairfax Summer Camp and its programming (“Claims”).

On my behalf and on behalf of my child I hereby release, covenant not to sue, discharge and hold harmless the Town of Fairfax, its employees, agents, and representatives, of and from the Claims including all liabilities, claims, actions, damages, costs or expensive of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Town, its employees, agents and representatives, whether a COVID-19 infection occurs before, during or after participation in any Fairfax Parks and Recreation program.
Signature*

Clear
Date (Today's Date)*

MonthDayYear
Date
PICTURE / VIDEO WAIVER

I give my consent and authorization for my child to be photographed while participating in the Fairfax Summer Camps. By willingly signing below, I grant the Town of Fairfax permission to use photographs and videos taken during these summer camps. Pictures and videos may be used for up to 10 years after the date they were captured.
Signature

Clear
Date (Today's Date)

MonthDayYear
Date
PERMISSION TO ATTEND CAMP

I, Parent / Guardian of the participant, authorize him / her to attend a 2023 Fairfax Parks & Recreation day camp.

I give permission for my child to go on trips by foot while accompanied by camp staff members away from the main camp location to BFA Fairfax and to the Fairfax Community Center.

I give permission for my child to swim in the camp's swimming area under the supervision of camp staff and with a certified lifegaurd present. I understand that if I do not want my child swimming, this should be communicated to the camp director and they will remain in a designated area with a staff member.

I give permission for my child to watch "G" or "PG" rated movies with staff members present during showings.

I give permission for the people I have listed to pick up my child. I understand that these people will be asked for identification if not recognized by camp staff members. I additionally acknowledge that my child will not be released to any person other than those I have listed.
Signature*

Clear
Date (Today's Date)*

MonthDayYear
Date
Payment
We will contact you within 72 hours of registration submission (Monday - Friday) to organize payment with you.

We have a very limited number of spots each week to offer reduced costs to families who cannot afford the full price of camp. If you would like to apply for a reduced rate for camp, please check "Yes" below and we will contact you with more information.
Would you like to apply for a reduced rate?

NoYes
Additional Notes

Please enter any additional information about your child you think we should know
Notes or Comments
Should be Empty:

Fairfax Summer Camp Registration

Child Information

Week Selection

Contact Information

Permissions

Payment

Additional Notes