City of Salisbury - Teen Summer Camp Information Form

CONTACT INFORMATION

Use this section to enter ALL contact information. Please enter parent's/guardian's names, utilize the phone number sections for the best contact phone numbers, and ensure that ALL contact information is entered. This information will be used In Case Of Emergency
Primary Parent / Guardian:*

First NameLast Name
Primary Parent / Guardian - Phone Number 1*
ex. (123) 456 - 7890
Primary Parent / Guardian - Phone Number 2*
ex. (123) 456 - 7890
Primary Parent / Guardian - Email #1:*
example@example.com
Primary Parent / Guardian - Email #2:*
example@example.com
Secondary Parent / Guardian:*

First NameLast Name
Secondary Parent / Guardian - Phone Number #1*
ex. (123) 456 - 7890
Secondary Parent / Guardian - Phone Number #2*
ex. (123) 456 - 7890
Secondary Parent / Guardian - Email #1:*
example@example.com
Secondary Parent / Guardian - Email #2:*
example@example.com
Authorized Guardians - Please enter all authorized pickup and drop-off persons (first and last name & phone numbers) for your participant separated by a slash (/). Anyone not listed on this, will not be allowed to pick up participants from camp.*

Participant Agreement, Waivers, and Release of Liability
In consideration of my child’s participation in this City of Salisbury Parks & Recreation Department program, I hereby voluntarily release, discharge, and agree to indemnify and hold harmless, on behalf of myself, my heirs, assigns, or personal representatives, City of Salisbury & City of Salisbury Parks & Recreation, their agents, assistants, officers, employees, volunteers, cosponsors and all other persons or entities acting in any capacity on their behalf from any and all claims, losses, injuries, and damages of any nature, including but not limited to, property damage and personal injury or death, attorneys’ fees and costs, which may arise from, relate to, or result because of my child’s participation in this experience.
By signing below, I am acknowledging this agreement for myself and any minor children for whom I am a parent or legal guardian.*

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Emergency Care: In the event of an accident or emergency that renders me unable to communicate for care of my child when I am unreachable, I grant my permission for any medical care which might become necessary.By signing below, I am acknowledging this agreement for myself and any minor children for whom I am a parent or legal guardian.*

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Field Trips/Transportation: I do hereby grant and give the City of Salisbury Parks & Recreation Department the right to transport my child to/from program sites by properly licensed staff. I am aware that my child must wear a seatbelt at all times when riding in a City-owned/operated vehicle. This includes travel for any and all field trips that may be a part of the week(s) that my child is signed up to attend. By signing below, I am acknowledging this agreement for myself and any minor children for whom I am a parent or legal guardian. *

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Media: I do hereby grant and give the City of Salisbury Parks & Recreation the right to use my child’s photograph or image with or without my child’s name, both singly and in conjunction with other persons or objects and presentations, advertising, publicity, and promotion relating thereto. By signing below, I am acknowledging this agreement for myself and any minor children for whom I am a parent or legal guardian.*

YesNo
MEDIA SIGNATURE:

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Will your child be permitted to walk home independently at 5:30 PM when the program ends? Please note that students must remain at the center for the entirety of the program unless a parent/guardian signs them out in person. Late pickups will result in a $10 fine per 10 minutes, and failure to pick up your child within 30 minutes will lead to suspension from the program the following day.

YesNo
By signing below, I confirm whether my child has permission to walk home independently at 5:30 PM when the program ends.

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In all circumstances, the City of Salisbury Parks & Recreation retains full authority for final approval and denial of activity registrations .Current and/or future participation in City of Salisbury Parks & Recreation activities may be canceled without refund for the following items, including, but not limited to:

• Unseemly conduct including failure to follow rules, policies, and procedures, general disruptive behavior, inappropriate language or attire, and/or verbal/physical altercations

• Health violations (spitting, smoking, etc.)

• Abuse of staff, program participants, property, or equipment

• Negligent or delinquent actions by participants

• Use or possession of illegal drugs and/or alcohol or violation of the City of Salisbury Parks & Recreation’s Smoke-Free Policy

• Use or possession of weapons or other dangerous items this program will follow a behavior guideline format in which ANY violation of these guidelines may result in expulsion from this program with no refund.

By signing below, I am acknowledging this agreement for myself and any minor children for whom I am a parent or legal guardian.
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I acknowledge that by signing my child up for the Miller Recreation Teen Center Summer Camp - 2025, that I or another authorized person (as their parent/guardian) will be REQUIRED to attend a parent meeting at 6:00 PM on Tuesday May 27th, 2025 at Miller Recreation Teen Center. (1402 W Bank St, Salisbury, NC 28144 ) By signing below, I am acknowledging this agreement for myself:*

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THANK YOU! WE CANNOT WAIT TO SEE YOU FOR THE SUMMER !
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City of Salisbury - Teen Summer Camp Information Form

CONTACT INFORMATION

Participant Agreement, Waivers, and Release of Liability

THANK YOU! WE CANNOT WAIT TO SEE YOU FOR THE SUMMER !