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2. Week 1

   1. June 29 - July 2 (no camp July 3)
3. Week 2

   1. July 6 - 10
4. Week 3

   1. July 13 - 17
6. Week 4

   1. July 20 - 24
7. Week 5

   1. July 27 - 31
9. Child's Last Name*
10. Child's First Name*
12. Age*

    as of June 29th

13. Entering Grade*

    1st Grade or Above

15. Allergies or Special Considerations
16. Current Medications
17. Last Tetanus
    Last Tetanus
19. Parent/Legal Guardian 1*
20. Phone Number*
21. Email Address*
23. Parent/Legal Guardian 2
24. Phone Number
25. Email Address
27. Address*
29. City*
30. State*
31. Zip Code*
35. Consent for Emergency Health Treatment

    Pennsylvania Law requires consent be given before medical, dental or health care services may be rendered to a minor, except where -in the judgment of the physican- an attempt to secure such consent would result in the delay of treatment, which would create a risk to the minor's life or health.  Even when consent has been provided, all reasonable efforts will be made to contact you or any persons listed as emergency contacts in connection with any emergency treatment.

    By checking the "I agree" box below, consent of undersigned Parent/Legal Guardian is hereby given to administer emergency medical, dental and health services to the minor child listed on this form. 

    1. I AGREE
37. Additional Authorized Pick-up Person(s) & Emergency Contacts

    List additional people authorized to pick up your child.  Proper identification is required and must be presented to the designated Camp Counselor at time of pickup or the child will not be released.

39. Authorization Type*

    1. Authorized to Pick Up
    2. Emergency Contact
40. Contact Name 1*
41. Relationship*
43. Phone Number*
44. Address*
46. City*
47. State*
48. Zip Code*
50. Authorization Type

    1. Authorization to Pick Up
    2. Emergency Contact
51. Contact Name 2
52. Relationship
54. Phone Number
55. Address
57. City
58. State
59. Zip Code
63. Primary Care Physician*
64. Phone Number*
65. Preferred Emergency Health Care Facility*
67. Health Insurance Carrier*

    All participants must be covered by health insurance.

68. Policy No.*
69. Group No.*
73. Minor (Child) Photo Release Form

    By checking the "I agree" box below, consent of the undersigned Parent/Legal Guardian is hereby given to Easttown Township and its agents and employees to use My Child's photograph publicly to promote the Summer Recreational Program.  I understand the images may be used in print publications, online publications, presentations, websites and/or social media.  I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

    1. I AGREE
75. Acknowledgement

    I, the undersigned Parent/Legal Guardian, understand that my child is expected to stay each day, Monday through Friday, 9:00 AM-12:00 PM, on the weeks they are registered.  I will take responsibility for his/her arrival and departure each day, and understand that failure to do so will result in my child not participating in the program, as determined by the Camp Director.  I understand that there is no assurance of my child's placement with a friend or particular group of children.  I agree that the Township and its recreational staff shall have the right to enforce rules and terminate participation by anyone failing to comply with the rules.

    I also acknowledge that the Easttown Township Summer Recreation Program involves active physical recreation and inherent risks, which could result in injury to the participant or damage to personal property.  The undersigned hereby assumes all risks and responsibility of possible damage or injury through participation in recreational activity and understands that insurance should be in place and furnished in case of injury.  I agree to indemnify and hold harmless the Township, its officers and employees for personal injury or property damage resulting from participation in the normal course of recreational activity.

77. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I AGREE
79. Parent/Legal Guardian Electronic Signature
80. Date
    Date
Leave This Blank:


82. 1. Receive an email copy of this form.
83. Email address

    This field is not part of the form submission.

84. Submit

* indicates a required field