FEES/HOURS $ (IF PAID BY JUNE 11 TH ) $ AFTER JUNE 11 TH TWO OR MORE CHILDREN ENROLLED IN PROGRAM: $ PER CHILD

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1 ACCOMACK COUNTY PARKS & RECREATION NUTRITION FITNESS & ENRICHMENT SUMMER PROGRAM REGISTRATION FORM Joynes Neck Road PO Box 134 Accomac, Virginia Wayne Burton, Manager ( ) FAX Parent/Guardian Information FEES/HOURS $ (IF PAID BY JUNE 11 TH ) $ AFTER JUNE 11 TH TWO OR MORE CHILDREN ENROLLED IN PROGRAM: $ PER CHILD PROGRAM START DATE: JUNE 25, 2018 PROGRAM END DATE: AUGUST 3, :30 AM 5:00 PM (MONDAY-FRIDAY) CLOSED: JULY 4, 2018 SITE LOCATIONS PUNGOTEAGUE ELEMENTARY ACCAWMACKE ELEMENTARY METOMPKIN ELEMENTARY KEGOTANK ELEMENTARY CHINCOTEAGUE ELEMENTARY T-SHIRT SIZE: YOUTH YOUTH OTHER ADULT - SMALL M, ADULT MEDIUM ADULT LARGE ADULT XL ADULT 2XL ADULT 3XL OTHER Participants Name Birthday Age Address Gender Parent/Guardian s 911 & Mailing Address Parent/Guardian s Contact Number/s (day) Child s Physician s Name Contact Number Insurance Provider Policy Number Name Insurance Policy Written In PROVIDE NAMES AND ADDRESSES OF 2 CONTACTS IF PARENT/GUARDIAN CANNOT BE REACHED Emergency Contact Contact Number Address Emergency Contact Contact Number Address

2 -2- PROVIDE THE FOLLOWING INFORMTION Allergies Yes No Medications Yes No Type and Dosage: Seizures Yes No Dietary restrictions Yes No Physical limitations/restrictions Yes No Easily Upset Yes No Physically aggressive (includes difficulty controlling temper) Yes No Withdrawn, shy Yes No Hyperactive Yes No *Parent/legal guardian must submit a Authorization for Medication Consent Form for non-prescription and/or Asthma medications. Parent must provide medication in the original labeled pharmacy/physician containers. All medications will be returned to the parent/legal guardian on the last day of the program. Contact Parks and Recreation office for the Authorization for Medication Consent Form. Person/s authorized to pick up your child/children Person/s not authorized to pick up your child/children (attach copy of divorce decree or other appropriate paperwork if parent is not allowed to pick up child) PHOTO RELEASE I give permission to have my child/children or my photo released for promotional purposes to the local media or for the County of Accomack Parks and Recreation Department s brochures and publications. Parent/Guardian s Signature Date:

3 -3- PARENT/GUARDIAN PLEASE READ AND SIGN I understand that ACCOMACK COUNTY PARKS AND RECREATION DEPARTMENT will make reasonable efforts to insure the health, safety, and welfare of the participants in all activities and all field trips; however it must be anticipated that an emergency, sickness, or injury may affect students participating in this NUTRITION FITNESS AND ENRICHMENT SUMMER PROGRAM. Neither ACCOMACK COUNTY PARKS AND RECREATION DEPARTMENT nor any employees of this department, is or shall be responsible for any injury, loss, or damage, including disappearance or death however caused, or the consequences thereof, which may occur during any part of the program, and said parent/guardian and student hereby waive and release any claim or cause of action against the county, the PARKS AND RECREATION DEPARTMENT, AND OR ITS EMPLOYEES for any such injury, loss, or damage; and said parent/guardian agrees to hold harmless and indemnify said county, department, and/or employee against any such claim or cause of action of any such student. I have read, understand and agree to the payment, and registration policies in this form. Parent/Guardian s Signature Date OFFICE USE ONLY OFFICE OTHER CASH CHECK MONEY ORDER RECEIPT NUMBER: DATE: EMPLOYEE S INITIALS

4 ACCOMACK COUNTY PARKS & RECREATION JOYNES NECK ROAD PO BOX 134 ACCOMAC, VIRGINIA , , FAX WAYNE BURTON, ACPR MANAGER AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT FOR MINOR CHILD *Note: This form will only be used if staff is unable to contact the parent or legal guardian CHILD S FULL NAME BIRTHDAY: List any significant health problems that might be significant to a physician evaluating your child in case of an emergency. I of (Parent/Legal Guardian Signature) (911 Address), Virginia whose contact number/s are is the parent or has legal custody of a minor, presently age who resides with me at the above address. I authorize WAYNE BURTON, ACPR MANAGER, OR BARBARA BOGGS, PROGRAM COORDINATOR adults in whose care the minor is entrusted from time to time for activities of the ACCOMACK COUNTY PARKS & RECREATION COMMISSION, when said child is so entrusted, to consent to any X-Ray examination, anesthetic, and dental or surgical diagnosis or treatment, and hospital care, to be rendered to the minor by any doctor licensed to practice in this state, any other state or the District of Columbia. I understand that the said WAYNE BURTON, OR BARBARA BOGGS will attempt to contact me at the above contact number/s prior to giving any such authorization in the event of any required emergency treatment, but I understand this authorization is expressly not conditioned upon any failure of the said WAYNE BURON, OR BARBARA BOGGS to contact me at the above number/s or in any other manner. I further agree to be responsible for any and all costs incurred as a result of such medical, hospital, or dental care or treatment rendered such child and further agree to indemnify and hold harmless the said WAYNE BURTON, BARBARA BOGGS, AND OR ACCOMACK COUNTY AND/OR ACCOMACK COUNTY PARKS AND RECREATION COMMISSION from any costs, claims, or causes of action resulting from the costs of expense of such care. I further release and waive my claim or cause of action and agree to hold harmless the said WAYNE BURTON, BARBARA BOGGS /ACCOMACK COUNTY AND/OR THE ACCOMACK COUNTY PARKS AND RECREATION COMMISSION against any and all claims, suits, liability, damages, loss, costs or expenses authorized by the said WAYNE BURTON OR BARBARA BOGGS to any such person named herein for the diagnosis, treatment or care prescribed herein. Print Parent/Guardian Name Relationship to Child I certify all the above information is correct. Date Signature of Parent/Guardian

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