TOWN OF VAN BUREN PARKS & RECREATION DEPARTMENT
SUMMER PLAYGROUND PROGRAM REGISTRATION
1st Child's Name:______Age:_____ D.O.B:______
2nd Child's Name:______Age:_____ D.O.B:______
3rd Child's Name:______Age:_____ D.O.B:______
Address:______
Mother's Name:______Phone # ______(H) ______(Work/Cell)
Father's Name:______Phone # ______(H) ______(Work/Cell)
Emergency Information: (In case a parent can not be reached - MUST be filled in!)
Contact:______Phone # ______(H) ______(W)
Special Health Information:______
Playground Site (circle one): REYNOLDS VAN BUREN PARK (PAVILION B)
MATERIALS & SUPPLIES FEE -- Covers entire 5 ½ -week program (CAN NOT BE PRO-RATED)
Playground Program Only (9am-2pm program):
Town Residents: $60.00 for each child / Non-residents: $70.00 per child registered
Playground Program plus Daycare Extension (Van Buren Park site only) 8:30am-5:00pm:
Town Residents: $295.00 per child / Non-residents: $305.00 per child (POOL NOT INCLUDED)
Town Residents: $330.00 per child / Non-residents: $340.00 per child (POOL PASS INCLUDED)
** Please note that the playground field trips (optional) are additional fees! If you wish to register your child (children) for any of the trips, please use the Playground Field Trip Registration Form (on back). Payment for trips is required at time of registration!
PLEASE MAKE CHECKS PAYABLE TO: TOWN OF VAN BUREN
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I am aware of the inherent dangers of the program being registered for and warrant that my child/children is/are in good physical condition. I understand that no medical insurance is included as a part of this program and will not hold the Town of Van Buren liable for any injury arising out of participation in this program.
______
Parent (or legal guardian's) signature Date
MAIL FORM TO (OR BRING IN): Van Buren Parks & Recreation, 7350 Canton Street, Baldwinsville, NY
13027-8767
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FIELD TRIP TOTAL: ______PLAYGROUND TOTAL: ______POOL PASS TOTAL: ______
AMOUNT: ______CHECK: _____ CASH: _____ RECEIPT: ______DATE: ______
(See back for Field Trip Registration Form)
SUMMER PLAYGROUND PROGRAM
FIELD TRIP REGISTRATION FORM
NOTE: Child MUST be registered for the Summer Playground Program to attend any of the field trips!
(Check each child participating)
FUN JUNCTION - Thursday, July 7 (MAX OF 65 KIDS PER SITE)
For this exciting trip, FUN JUNCTION will allow us unlimited laser tag and arcade games (that do not dispense tickets)! If you would like to play all of the arcade games, please bring extra money. We’ll be there from 9:45 to 11:45am. Lunch will be eaten back at the playground. Bring a bag lunch as usual.
______1st child COST PER CHILD: $16.00 Registration deadline: Fri., July 1
______2nd child
______3rd child
Receipt # ______Date: ______TOTAL FEE: $______
BOWLING@FLAMINGO BOWL-- Thursday, July 14 (MAX OF 90 KIDS PER SITE)
Join us at the Sports Bowl for two hours of bowling! Price per child includes three games and shoe rental. (Lunch will be eaten back at the playground. Bring a bag lunch as usual)
______1st child
COST PER CHILD: $11.00 Registration deadline: Fri., July 8 ______2nd child
______3rd child
Receipt # ______Date: ______TOTAL FEE: $______
THE HOLLYWOOD THEATER - Thursday, July 21 (MAX OF 65 KIDS)
A trip to the movies. Join us for a PG/G rated movie (movie to be announced later on) as well as a small popcorn and small soda.
**We will be leaving the playground at 9:05am. Please make sure the kids are at the playground at 9:00 sharp!
COST PER CHILD: $12.00 Registration deadline: Fri., July 15 ______1st child
______2nd child
______3rd child
Receipt # ______Date: ______TOTAL FEE: $______
THE ZOO – Thursday, July 28 – Raindate Friday, July 29** (MAX OF 65 KIDS)
For this trip we will be going to the Rosamond Gifford Zoo. Cost includes entry, a snack and a drink while the kids are there. Kids will need
to pack a lunch for when they get back to the playground.
COST PER CHILD: $10.00 Registration deadline: Fri., July 22 ______1st child
______2nd child
______3rd child
Receipt # ______Date: ______TOTAL FEE: $______
FUN JUNCTION - Thursday, August 4 (MAX OF 65 KIDS PER SITE)
For this exciting trip, FUN JUNCTION will allow us unlimited laser tag and arcade games (that do not dispense tickets)! If you would like to play all of the arcade games, please bring extra money. We’ll be there from 9:45 to 11:45am. Lunch will be eaten back at the playground. Bring a bag lunch as usual.
______1st child
______2nd child
COST PER CHILD: $16.00 Registration deadline: Fri., July 29
______3rd child
Receipt # ______Date: ______TOTAL FEE: $______
TOTAL FOR ALL TRIPS: $______