LYDIA
HAWK
LACEY PARKS & RECREATION
SUMMER DAY CAMP 2014
Camper’s
Name
(last)
M/F
(circle one)
(first)
City
Address
ZIP
Home Phone (
Date of Birth
)
Email Address
Tell us more about your child
Please fill out the information on the reverse side of this form
Two weeks payment in advance must be made at the time of registration to hold
Please your spot for the summer (check, cash, or credit card). After this, payment is due
initial the Monday prior to the week your child(ren) are attending, or you will be charged
a $10 late fee and possibly withdrawn from camp to accommodate the waitlist.
CHECK
WEEK
HERE
1
DATES OF CAMP
FEE
June 23-27
$145
PARTY IN THE USA
$145
July 14-18
$145
July 21-25
$145
July 28-August 1
$145
$145
7
August 4-8
LITTLE CREATURES
$145
8
August 11-15
MY, OH MY!
August 18-22
$170*
4
SEARCHIN’ FOR SASQUATCH
CHARLIE’S SAFARI
THERE’S A STORM COMING
CHILDREN’S THEATRE
5
IT’S A JUNGLE OUT THERE
6
MIDSUMMER MARVEL
9**
REFUND POLICY
Notice Received
Refund
Thursday by 5:00pm
before 1st Camp Day 100%
$130
July 7-11
3
DATE
Let’s Get This Party Started!
June 30-July 3
2*
AMOUNT
PAID
*Exceptions: Week 2 = $130
**Week 9= $170
R
FO CE
FI
F
O SE
U
Y
L
ON
R
FO CE
FI
F
O SE
U
Y
L
ON
LET’S DO IT ALL AGAIN! BRING YOUR SACK LUNCH EVERYDAY!
Rainier Vista Comm. Park FIELD TRIP EVERYDAY!!!!!!!!!!!!!!
After 1st Camp day
After 2nd Camp day
On 3rd Camp day
75%
50%
0%
*** T-SHIRT SIZE ***
(one shirt per child for summer)
Youth
Small
Adult
Small
Youth
Medium
Adult
Medium
Youth
Large
Adult
Large
2014
H:\Summer Day Camp\2014\registration form.indd
OVER
Parent/Guardian/Name (print please)
Parent/Guardian (signature)
Lacey Parks & Recreation
420 College Street SE
Lacey, WA 98503
360.491.0857
Child’s Name (print please)
EMERGENCY INFORMATION
Who do we call in case of emergency during the day?
NAME_________________________________RELATIONSHIP_________________________
Home Phone__________________Work Phone________________Cell Phone________________
NAME_________________________________RELATIONSHIP_________________________
Home Phone__________________Work Phone________________Cell Phone________________
PERMISSION TO RELEASE
Please list anyone else that has permission to pick up your child.
Persons not listed here will not be able to pick up your child.
NAME_________________________________RELATIONSHIP_________________________
NAME_________________________________RELATIONSHIP_________________________
NAME_________________________________RELATIONSHIP_________________________
NAME_________________________________RELATIONSHIP_________________________
NAME_________________________________RELATIONSHIP_________________________
NAME_________________________________RELATIONSHIP_________________________
HEALTH INFORMATION
Allergies? (plant, insect, food, medication)____________________________________________
Special dietary needs?___________________________________________________________
Taking any medication?___________________________________________________________
RELEASE
I DO__DO NOT__ give permission for non-prescription medication (non-aspirin product, Neosporin) to be given
to my child.
I DO__DO NOT__ In case of emergency only, give permission to the physician selected by the camp staff
personnel to hospitalize, secure treatment for, and order injections, anethesia, or surgery for my child named
on this form. Any directions to the contrary should be specified on this form with signature of parent/guardian.
I fully realize that there are certain inherent risks to which my minor child(ren) will be exposed because of the
nature of this activity. Fully understanding those risks, I hereby release the City of Lacey, its officers and
employees, from any damages that may be suffered through particiaption in any activity related to the Lacey
Parks and Recreation Summer Day Camp.
I DO__DO NOT__grant the City of Lacey permission to use and publish my child’s name or otherwise identify my
child in association with any photo in which my child appears for editorial, marketing and promotional purposes in print
and electronic media. No financial or other liability to me will be incurred by the city or the photographer.
H:\Summer Day Camp\2014\registration form.indd