City of Fort Myers S.T.A.R.S. Summer Camp Pre-Registration Form

PLEASE READ ALL INFORMATION AND REQUIRED STEPS BEFORE PROCEEDING.

1)Create an Account in Web Trac-using the attached link

City of Fort Myers STARS/Recreation Web Trac Create Account

2) Complete the below Pre-Registration Form (there are no paper applications)

3) Complete the Registration on March 19, 2021 6pm-9pm at the S.T.A.R.S Admin Office at 2980 Edison Ave. Process is pending until Payment Plan or payment in full has been secured.

***SPACE IS LIMITED and STARS will only accept Registration on March 19, 2021 6pm-9pm. ***

Select the Camp type- Full Camp/Or Special Skills *

Primary Parent/Guardian Name *

First Name Last Name

Email *

example@example.com

Phone Number *

Area Code Phone Number

Home Address- Proof of residency will be required *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Participant Names *

Emergency Contacts/Pick Up List *

Authorizations- Please read carefully

Participation

I give permission for my child to participate in all activities, including field trips and swimming, and to be transported as authorized by the City of Fort Myers S.T.A.R.S. Division.
I give permission for the City of Fort Myers S.T.A.R.S. Division to use any pictures of my child for future promotional purposes.

Medical Treatment

I hereby give permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a qualified staff member of the City of Fort Myers S.T.A.R.S. Division in the event of emergency, I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I further consent to the disclosure of health information and to the medical, surgical and hospital care treatment and procedures (including, but not limited to, administration of necessary anesthetics, tests, x-ray examinations, transfusions, injections, drugs) to be performed for my child by a licensed physician or hospital selected by the City of Fort Myers S.T.A.R.S. Division Manager when deemed immediately necessary or advisable by the physician to safeguard my child’s health.

Release from Liability

As a participant in the City of Fort Myers S.T.A.R.S. Program(s), I acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any injuries including loss of life, damages or loss which my child may sustain because of participating in any and all activities connected with or associated with such program. I agree to waive and relinquish all claims, fully release and discharge and agree to indemnify and hold harmless and defend the City and its officers, agents, and servants and employees from any and all claims resulting from injuries, including loss of life, damages and losses sustained by me arising out of, connected with, or in any way associated with the activities of the program. I have read the City of Fort Myers S.T.A.R.S. Division Program Rules and Regulations. I realize that my child may be suspended or expelled for failing to follow the rules.

For the protection of my child, I or a designated adult will sign my child out when they leave the City of Fort Myers STARS facility location. I will advise City of Fort Myers STARS Division personnel if my child will be picked-up after 6 pm.

Photo Release:

The applicant hereby gives permission for the City of Fort Myers S.T.A.R.S Division to use, without limitation or obligation, photographs or other media that may include the members’ image or voice to promote or interpret City of Fort Myers S.T.A.R.S. Division

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.

Signature *

Clear

THE STAFF AT THE City of Fort Myers S.T.A.R.S. Division IS VERY CONCERNED WITH THE WELFARE OF OUR CHILDREN. WE NEED YOUR HELP IN INFORMING US OF ANY ILLNESS OR SPECIAL NEEDS THAT YOUR CHILD WILL HAVE. City of Fort Myers S.T.A.R.S. STAFF DOES NOT ADMINISTER MEDICATIONS OF ANY KIND. Please check any of the following medical conditions that may apply to your child.

I, {primaryParent}____________ the parent/ guardian of the above named student recognizes that as a result of participation in activities, medical treatment in an emergency may be necessary and further recognize that the S.T.A.R.S. personnel may be unable to contact me for my consent for emergency medical care. I do hereby consent in advance to such emergency care, including hospital care, as may be deemed necessary under then existing circumstances. Please make notation of my son/ daughter’s records below.

Signature *

Clear

Health Information *

PLEASE NOTE: BY SUBMITTING THIS APPLICATION IT DOES NOT GUARANTEE A SPOT FOR YOUR CHILD. WE MUST RECEIVE YOUR PAYMENT OR DEPOSIT FOR PAYMENT PLAN TO GUARANTEE A SPOT. Payments can only be made in person at the S.T.A.R.S Administrative Offices located at 2980 Edison Avenue, Ft Myers, FL 33916. The Registration date is March 19, 2021 6pm-9pm Please call (239) 321-7545 ext# 5 with any questions

Camp Registration includes a non-refundable administrative fee of $15.00
Camp Registration must be paid in full by May 21, 2021
There are no refunds for of any kind once Summer Camp begins on June 21, 2021