The Town of Stony Point

www.townofstonypoint.org > Recreation Department > Playground Program Registration

Town of Stony PointPlayground Program

Town of Stony Point Camps

Child's Name:

Sex:

Address:

DOB:

Age:

Grade:

Parents Names:

Telephone:

Cell:

Email:

Emergency Contact:

Phone:

Family Doctor:

Telephone:

Please select week(s) registering for:

I agree.

(by not agreeing you will not be permitted to register for the Town’s Camp Programs):

PLEASE MAKE CHECKS PAYABLE TO: Town of Stony Point

** I hereby give consent for my child to participate in the program indicated.

I give permission for pictures to be taken of my child:

In the event a parent cannot be reached I authorize my child to be treated by either an EMT, physician or other medical staff:

Please Note: Our programs are licensed by the NYS Dept. of Health and requires two inspections yearly. Inspection reports concerning the camps are filed in the Directors offices.

Medical History

Child's Name:

List any chronic illnesses:

List any special needs, allergies, diets, other restrictions:

List any medications or treatments:

List any other conditions that we should be aware of

PLEASE SUPPLY A COPY OF CURRENT IMMUNIZATION RECORDS.

NO CHILD CAN ATTEND THE PLAYGROUND PROGRAM WITHOUT A COPY OF IMMUNIZATION RECORDS ON FILE.

To the best of my knowledge the above information is correct.

Parent/Guardian Signature:

NO REFUNDS OR PRO-RATED FEES

** Proof of residency and payment must be provided to secure your child's spot. 60 campers will be accepted per week.