Summer Program

Please fill out the form below if you would like to register your child for our Summer Program.

Name of Child * First Last
Date of Birth * / MM / DD YYYY
Grade Entering
Parent #1 Name * First Last
Parent #1 Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Parent #1 Phone * - (###) - ### ####
Parent #1 Cell - (###) - ### ####
Parent #1 Work Phone - (###) - ### ####
Parent #1 Email
Parent #2 Name First Last
Parent #2 Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Parent #2 Home Phone - (###) - ### ####
Parent #2 Cell Phone - (###) - ### ####
Parent #2 Work Phone - (###) - ### ####
Parent #2 Email
Emergency Contact Information
Emergency Contact Name * First Last
Emergency Contact Relation to Child *
Emergency Contact Home Phone * - (###) - ### ####
Emergency Contact Cell Phone - (###) - ### ####
Permission to pick up child * First Last
Permission to pick up child First Last
Permission to pick up child First Last
Permission to pick up child First Last
Permission to pick up child First Last
Medical Information
Is your child's Tetanus shot current for September 2010 through September 2011? * Yes No
Child's Physician First Last
Physician Phone - (###) - ### ####
Physician Phone - (###) - ### ####
Is your child covered by an insurance plan? * Yes No
Name of Insurance Company
Please list all allergies your child has (if none, please type "none known" in box below). *
Please list all medications your child is on (if none, please type "none" in the box below). *
Please list any health conditions your child has (if none, please type "none" in the box below). *
Has your child had an IEP behavioral modification plan? If yes, please provide a copy within 14 days of completing this form to the Hermon Recreation Office * Yes No
I give Hermon Recreation permission to use my child's captured media images for advertising and special announcements. * Yes No
Swimming Pool Information
To help us prepare for fun in our pool, we ask that parents provide us with some information about your Camper's swimming ability. *
Floatation device required? If yes, please provide the required floatation devices. * Yes No
I understand that if my child requires floatation devices, they will not be allowed to swim without them. * Yes
I understand that my child is required to bring a towel, swimsuit, and a change of clothes daily. * Yes
I understand that my child is required to bring a lunch and two snacks each day, and a water bottle is recommended. * Yes
Release Information: I hereby authorize my child to participate in Hermon Recreation Department Programming. I agree to hold harmless the Recreation Department, the Town of Hermon, and the Hermon School Department for any injuries that could arise during participation. I authorize the Hermon Recreation Department and its employees to act in my place in all respects and with all immunities should the need arise to administer emergency medical care.
By typing your name in this field you hereby attest that the information provided in this form is truthful and accurate and that you have reviewed the release information. * First Last
Date * / MM / DD YYYY

Summer Program

Summer Program

Emergency Contact Information

Medical Information

Swimming Pool Information