3/16/23 Summer Playground PopUp Registration Form

Summer Playground Registration
Child(ren) Information
1st Child's Name*

First NameLast Name
Gender*

MaleFemale
Birth Date*

MonthDayYear
Grade*
Grade in Fall 2022
2nd Child's Name

First NameLast Name
Gender

MaleFemale
Birth Date

MonthDayYear
Grade
Grade in Fall 2022
3rd Child's Name

First NameLast Name
Gender

MaleFemale
Birth Date

MonthDayYear
Grade
Grade in Fall 2022
4th Child's Name

First NameLast Name
Gender

MaleFemale
Birth Date

MonthDayYear
Grade
Grade in Fall 2022
*If you have more than 4 children please complete this form and email director@pottsgroverec.com additional children names, birthdate, grade, medical, allergies, etc.
Do you plan on registering your child for Summer Playground this year? Please tell us which weeks you plan to send your child below (If this will be different for each child please email Pam director@pottsgroverec.com):

June 20 - June 23 (No Playground on June 19)June 26 - June 30July 3 - July 7 (No Playground July 4)July 10 - July 14July 17 - July 21
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
Mother/Guardian's Name*

First NameLast Name
Mother/Guardian's Phone Number*

Area CodePhone Number
Mother/Guardian's E-mail
example@example.com
Father/Guardian's Name*

First NameLast Name
Father/Guardian's Phone Number*

Area CodePhone Number
Father/Guardian's E-mail
Emergency Information
1st Emergency Contact's Name

First NameLast Name
Relationship
Emergency Contact's Phone Number

Area CodePhone Number
2nd Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Medical Information: All medical information is kept strictly confidential. It is extremely important that we have all necessary medical information concerning your child. This also includes any learning disabilities.
Does your child(ren) have any allergies?

yesno
medical conditions?

yesno
medications?

yesno
Does your child require accommodations due to health, physical, social, cognitive and/or behavioral needs?

yesno
Please Explain any yes answer for allergies, medical conditions, medications, or special accommodations - please list child's name if you have more than one.
PRB Medication Policy

The responsibility for administering medications rests with the camper’s legal parent or guardian. No camp staff is permitted to administer medication. It is important that all medication be taken at home. No medication is to be sent to camp unless it is a prescription drug for preventive reasons or emergency conditions such as seizures, heart conditions, asthma, bee stings or allergy conditions. These preventive or emergency medications may be sent to camp if the rules listed below are followed:

1. Note from the doctor stating name of medication, how it is to be given, amount, time and diagnosis of illness. The medication must have the prescription label on the container.

2. Note from the parent or legal guardian giving approval for the medication to be administered by the camper under staff supervision or Site Supervisor or Leader if camper is unable to administer due to an emergency.

HOLD HARMLESS AGREEMENT

Any participant and/or guardian do hereby agree to the following:

1. To assume all risks and responsibilities of possible damage or injury involved through participation in said activity. I understand I am to furnish my own insurance in case of injury. Understand and request permission to participate in the above activity with the full knowledge that the said activity could result in damage or injury to participant.

2. Agree to indemnify and hold harmless the Pottsgrove Recreation Board, its departments and agents from liability for personal injury or property damage resulting from my participation in said activity.

3. Waive the right to dispute all proper charges once he/she/they have registered and/or participated in the PRB program for which this registration form is received

4. Agree to allow Pottsgrove Recreation Board to use any photos taken at an activity for future publications.

5. By providing my email address, I agree to receive emails from Pottsgrove Recreation Board. Email will not be shared with any other entities.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Parent/Guardian's Signature

Clear
Please check here to mail check. SKIP PAYMENT SECTION BELOW. Please note registration is not complete until payment is received. Please email Pam: director@pottsgroverec.com with questions.

My Products

March 16, 2023 - $10/child$12.00

No discount for multiple children under 5 weeks. There is also an added convenience fee for paying online.

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Total $0.00

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Summer Playground Registration