Roseland Recreation Department 973/403-6822

Mayor John Duthie

2016 SCRAM(GRADES 1-9) Summer Playground “With the Camp Atmosphere”

Arts and Crafts * Sports * Games * Clinics/Entertainment * Special Trips for Roseland Boys and Girls

Doors open at 8:30 a.m. SHARP and close 1:00 p.m. SHARP

Located at BondForce Memorial Park, 298 Eagle Rock Avenue, Roseland

(All grades will be dropped off at the First Aid Squad building at the rear of the park.)

When: Mon. June 27th - Fri.August 5th - Monday through Friday - rain or shine-NO program on Monday, July 4th

Cost: $300.00 per child per session for the entire 6-week program

DEADLINE: Friday, June 10th or when the maximum number of participants is reached (whichever comes first), all others will be

placed on a Waiting List, and added if space becomes available. Registrations will be done on a “first-come, first-served” basis.

REFUND POLICY APPLIES - There is a $25.00 processing fee on all refunds. MAKE CHECKS PAYABLE TO: BOROUGH OF ROSELAND -

Mail or walk into: ROSELAND RECREATION DEPARTMENT, 140 Eagle Rock Avenue, Roseland, NJ 07068

PARENTAL NOTES: 1. There may be up to six day trips. Some trips, if not all, may extend playground time. A nominal fee may be charged for each special trip. 2. Children will not be allowed to leave the playground without written permission. A parent/guardian must be present to sign in and sign out a child every day. 3. Packet pick-up day (shirts, policy, schedules and trip forms) at Roseland Recreation is on or after Wednesday, June 22nd.

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EACH SCRAM PARTICIPANT NEEDS A FORM DETACH HERE OFFICE USE ONLY-DO NOT WRITE BELOW

______

CASH CHECK # AMOUNT DATE REC’D.

CHILD’S NAME ______E-MAIL ADDRESS ______

ADDRESS ______CELL / HOME PHONE ______/______

EMERGENCY PHONE______GRADE (FALL ’16) ______

(Check off t-shirt size) Youth: S ____ M____ L____ Adult: S ____ M ____ L ____ XL ____

DOES YOUR SON/DAUGHTER HAVE ANY HEALTH CONDITION(S) THE STAFF SHOULD KNOW ABOUT? No_____

Yes, Explain ______

The Recreation Department recommends the disclosure of relevant health information. Unless the Roseland Recreation Department is notified in writing, staff will be forwarded all information on the Registration Form, including any health conditions.

Child Photo / Video / Release Form

I grant permission for the Borough of Roseland, Roseland, New Jersey to use photograph(s)/moving image(s) of my child participating in Borough programs and/or activities for promotional purposes. I understand that photographs or recordings may be utilized by the Borough at its discretion for materials including, but not limited to: newsletters, brochures, television, video tape and flyers. Photographs sent to the local newspaper may have names noted. There will be no valuable consideration paid as a result of this activity. Yes ___ No ___

PARTICIPANT WAIVER OF CLAIM FORM: As partial consideration for the Borough of Roseland providing ______(“Participant”) with the opportunity to participate in SCRAM I, ______, as parent or guardian of Participant, on his or her behalf and on my own behalf and that of my spouse or partner, agree to hereby 1) acknowledge that there are foreseeable and unknown risks inherent in participation in the Program, 2) release, indemnify and hold harmless the Borough of Roseland, it officials, departments, employees, volunteers, contractors, insurers, including the NJIIF and the Borough of Roseland, its owners, employees, volunteers and subcontractors from and against all claims, losses, costs an damages arising from Participantparticipation in the Program, and 3) agree that for any loss or damage suffered by Participant will be turned over to parent / guardian’s insurance company. I also represent that the Participanthas been cleared by his/her physician to participate in the Program. If a medical emergency should arise and the parent / guardian cannot be reached immediately at the home phone # (______), at the work phone # (______), at the emergency phone # (______) or via the cell phone # (______), I, parent or guardian, hereby grant medical personnel to take whatever means he or she deems necessary to safeguard the welfare of the Participant.

Print Name ______Signature______Date______

SURVEY QUESTION: If SCRAM were to have extended “Full Day” hours in 2017, would you be interested?

Yes______No______

WE ARE LOOKING FOR PROGRAM SPONSORS. PLEASE CHECK HERE IF INTERESTED ______

For more information turn to Comcast Channel 35 or Verizon Channel 46, check out our Website at look in “The Progress” newspaper.