2018 Winter Break Camp Registration Form

WINTER BREAK CAMP REGISTRATION FORM
275 Beasley Drive - Versailles, KY 40383
www.vwcparksrec.com - (859) 873-5948

PARTICIPANT INFORMATION

Participant's Name *

First Name Last Name

Birthdate *

- Month - Day Year

Gender *

Grade in School *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Who does child live with at this address? (Check all that apply) *

Mother Father Grandmother Grandfather Legal Guardian

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name *

First Name Last Name

Relationship to Participant *

Parent/Guardian E-mail *

Parent / Guardian Cell Phone *

Parent / Guardian Home or Work Phone *

Additional Emergency Contact *

First Name Last Name

Relationship to Participant *

Does the emergency contact reside at the same address as above?

Emergency Contact E-mail *

Emergency Contact Cell Phone *

Emergency Contact Home or Work Phone *

MEDICAL/ALLERGY INFORMATION

Insurance (if none, type "None") *

Hospital Preference *

1. Does your child have any allergies we should be aware of (eg: food, medicine, latex, bee stings, etc)? *

Yes No

If yes, please describe any allergies. Be very specific. *

2. Is your child on any medication we should be aware of? *

Yes No

If yes, please give the exact name of the medication your child is on, side affects, etc. *

3. Does your child have a medical condition of which we should be aware? *

Yes No

If yes, please explain these medical conditions here: *

AUTHORIZATION FOR MEDICAL CARE:

In the event that emergency medical care is required, I give permission for a representative of the Recreation Department and/or ambulance service to transport my child to the nearest medical facility to render treatment.

By typing my name below, I acknowledge that I have read and agree to the Authorization for Medical Care and I understand and acknowledge that by typing my name below I am delivering an electronic signature that will have the same effect as an original, handwritten signature and that the electronic signature will be equally as binding as a handwritten signature.

Please type name here *

Date *

- Month - Day Year

SWIMMING & MOVIE PERMISSION PERMISSION SLIP

SWIMMING:

My child may go swimming: *

My child must wear a lifejacket: *

My child may go up to this depth: *

MOVIES:

My child may watch movies while at camp: *

If yes, my child may watch movies rated: *

SWIMMING/MOVIE PERMISSION SLIP:

I give my child permission to participate in the above listed activities that are planned and supervised by Versailles-Woodford County Parks & Recreation Department and its camp staff.

By typing my name below, I acknowledge that I have read and agree that my child may participate in the swimming & movie activities listed below and I understand and acknowledge that by typing my name below I am delivering an electronic signature that will have the same effect as an original, handwritten signature and that the electronic signature will be equally as binding as a handwritten signature.

Please type name here *

Date *

- Month - Day Year

WAIVER OF LIABILITY & TERMS OF PARTICIPATION:

As a participant in this Versailles-Woodford Co. Parks & Recreation Program, I recognize and acknowledge that there are certain risks of injury and I waive and relinquish all claims I or my children may have as a result of participation in this program against Woodford County, the City of Versailles, the Versailles-Woodford Co. Parks & Recreation Department and it’s officials (either elected or appointed), commissioners, officers, agents, employees and volunteers. I further agree to indemnify, hold harmless and defend Woodford County, the City of Versailles, Versailles-Woodford Co. Parks & Recreation and it’s officials (either elected or appointed), commissioners, officers, agents, employees and volunteers from and against any and all claims, suits or cause of actions, including reasonable attorney’s fees, sustained or caused by myself or my child arising out of, in connection with, or in any way associated with the activities of this program.
I give my child/children permission to participate in this program and on the child’s behalf as parent and/or legal guardian I hereby waive, release and forever discharge any and all claims against the County of Woodford, the City of Versailles, the Versailles-Woodford Co. Parks & Recreation Department and it’s officials (either elected or appointed), commissioners, officers, agents, employees and volunteers for damages and/or injuries which may arise from my child’s participation in this program.
I, the undersigned, understand and acknowledge that participation in a recreational activity can be hazardous and I realize that no one should enter into a recreation activity unless the participant is medically able. I/We assume all risk associated with this activity including, but not limited to falls, contact with other participants or equipment, effects of weather, equipment failure and condition of playing area. I fully understand that is my responsibility to ascertain if this specific activity contains other elements of risk that could prove to be harmful to a participant. I understand that the VWCPRD does not provide medical insurance coverage for program or league participants.
Having read this waiver and in consideration of acceptance of entry into this program, I and anyone entitled to act on my behalf waive and release Woodford County, City of Versailles, Versailles-Woodford Co. Parks & Recreation, it’s co-sponsors, their representatives and successors from all and against any and all claims, suits, or cause of actions, including reasonable attorney’s fees, sustained or caused by myself or my child arising out of, in connection with, or in any way associated with the activities of this program.
I understand that registration fees must accompany this application in order for it to be processed. (Please make checks payable to VWCRPD. If you have any questions concerning fees, please contact the department at 873-5948.) Refunds are not granted after a program meets one time (refunds are not granted in competitive sports league after teams have been drafted). In the case of injury or illness preventing participation of myself or my child, a pro-rated refund will be granted if a doctor’s note is received within 10 business days of seeking treatment.
I understand and give permission for the Parks and Recreation Department or local media to photograph or video tape my child or me during participation in Parks and Recreation activities and to use them in advertising and promotion, both in print and on the Department’s website and social media outlets.
In the event of an emergency, I give my permission for a representative of the Recreation Department and/or ambulance service to provide treatment as is normal and prudent and to transport my child or myself to the nearest medical facility to render treatment.

I have read and agree to the above conditions *

Yes No

By typing my name below, I acknowledge that I have read and agree to the Waiver of Liability & Terms of Participation. I also understand and acknowledge that by typing my name below I am delivering an electronic signature that will have the same effect as an original, handwritten signature and that the electronic signature will be equally as binding as a handwritten signature.

Please type name here *

Date *

- Month - Day Year

PROGRAM REGISTRATION:

Select if your child will be coming one day ($30) or multiple days ($25/day) *

Winter Break Camp - 1 Day $ 30.00

Winter Break Camp - Multiple Days $ 25.00

Quantity

Enter coupon

Total $ 0.00

Please tell us what days your child will attend Winter Break Camp: *

Thu, Dec 20 Fri, Dec 21 Wed, Dec 26 Thu, Dec 27 Fri, Dec 28 Wed, Jan 2

PICK-UP LIST:

Please list the names of all individuals who are permitted to pick your child up from camp (including parents or guardians). Please note, if our staff does not know the person picking your child up, they will be required to show a photo ID before your child will be allowed to leave with them.

Name *

First Name Last Name

Name

First Name Last Name

Name

First Name Last Name

Name

First Name Last Name

After completing this form, please click Submit Form. You will receive a confirmation email. If you do not receive the email within a few minutes, please check your spam; otherwise, please contact us at rjohns@vwcparksrec.com.