randall`s island summer camp 2016

FORM # 2
RANDALL’S ISLAND SUMMER CAMP 2016
NAME OF HOME (CBO) AGENCY _________________________________________
Camper Registration Form
(to be completed by campers and parents)
NAME ____________________________________________________________________
PARENT/GUARDIAN _______________________________________________________
STREET ____________________________ APT. ____ BOROUGH ______ ZIP ________
PHONE _____________________________ DATE OF BIRTH ______________________
EMERGENCY CONTACT ____________________________ PHONE ________________
ADDRESS _________________________________________ PHONE ________________
SCHOOL __________________________________ GRADE (as of 9/2016) ____________
ADDRESS _________________________________________ PHONE ________________
HEALTH
Are you in good health? YES ______ NO ______
Are you asthmatic? YES ______ NO _______
Do you take any medication? YES _____ NO _____ Name of medication ________
Do you have any known allergies? YES _____ NO _____ If yes please explain ___
____________________________________________________________________
INSURANCE
Does your family have medical insurance? YES _____ NO _____
Health insurance carrier ____________________________ Policy # ____________
Have you suffered any injuries or had any health problems in the last 6 months?
YES _____ NO _____
Describe ____________________________________________________________
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FORM # 2
ACTIVITY SELECTION (campers will be rotated throughout all activities, however, we will
try to honor your choices whenever possible)
(1 for the first choice, 2 for the second, 3 for the third)
Basketball __ Tennis __ Horseback ___ Volleyball __ Kickball ___ Lacrosse ___
Softball ___ Nature ____ Physical Fitness ____ Wiffleball ____ Track &Field ___
Disc Activities _____Golf ___Mini Golf ___ Soccer ___ Dance ____Percussion ___
Rugby______ Self Defense_____ Bike NY_____ Capoeira ____ Urban Farm____
Waiver
Release and Waiver: I hereby release and hold harmless Randall’s Island Park Alliance, Inc. (RIPA), and the New
York City Department of Parks & Recreation (Parks), including successors, assigns, officers, directors and
employees and all related parties contracted by the aforementioned of any and all liability, claims, and demands of
whatever kind or nature, which arise or may hereafter arise from any harm to my child suffered during or as a result
of his/her participation in camp or transportation to camp. I further acknowledge and agree that there are certain
inherent dangers in playing sports and that neither RIPA shall be liable for any personal injuries, property damage,
or other loss sustained by the undersigned or by my child in, on or about Randall’s Island, or arising out of the use or
intended use of any facilities, equipment or other property during the summer camp.
Medical Treatment: To the best of my knowledge, my child is in good physical condition and may participate
safely in camp. I hereby release RIPA and Parks from any claim which arises on account of any first aid, treatment,
or service rendered to my child in connection with any incident at Randall’s Island Park.
Indemnity: I will indemnify RIPA and Parks for any damage caused or liability incurred by my child during his/her
visit to Randall’s Island Park.
Photographic Release: I understand that my child’s photograph may be taken during camp and hereby allow RIPA
staff to take photographs, videos and/or audio recordings, which contain images of my child. I understand that these
images may be used by RIPA, and agree to allow them to publish or reproduce such images.
Commitment: If selected for camp, my child will be committed to attending each day, unless unforeseen
circumstances arise. My child will also follow the rules of camp and behave in a sportsmanship like manner at all
times.
Other: I understand that this Release shall be governed by and interpreted in accordance with the laws of the State
of New York. I agree that in the event that any provision of this Release shall be held to be invalid by any court, the
invalidity of such provision shall not otherwise affect the remaining provisions of this Release which shall continue
to be enforceable.
Parent/Guardian’s Signature______________________________ Date _________________
CBO Directors and parents please note:
• Participants are required to provide their own lunch and transportation each day.
• Participants must provide certification that current physicals have been obtained.
• All campers must have medical clearance to attend Randall’s Island Summer Camp.
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