Playground Program 2017
UpperBernTownship would like to invite your child to a summer of fun and sun!
UBT will hold summer playground from Monday, June 12, 2017 through Friday, August18, 2017 from 9 am - 4 pm daily, rain or shine. All children attending kindergarten in August of 2017 through age 15 are welcome to attend.
Our agenda will include arts & crafts, sports, games and an optional snack time.If you choose to send your child with refreshments, refrigeration is available.We also take field trips which are at your cost. Please send your child with a lunch as lunch will not be provided for them.
There is a playground fee of $5.00 per child per week. Please have cash, check or money order ready at registration.Weekly fee is due on the first day of the week the child attends. Any field trips will be extra and will be the responsibility of the parent/guardian.
Only children having the form will be allowed to participate in field trips and the leaders will assume no responsibility for any child without a permission slip.
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Child’s Name: / Age:Address:
Parents’ Names:
Insurance Co. Name: / Policy / ID #:
Hospital Preference: / Emergency Contact / Phone Number:
Email Address for Parent: / Transportation:
Pick-up Walk
Names of Person with Approval to pick the child up. / Phone Number of person to pick up child
Please list all Allergies and action that should be taken if a problem occurs:
Is your child permitted to take the basic medications listed: (ie, Tylenol, antacids, Benadryl, etc) (If your child needs other medications, please send them with your child with instructions.) / Please initial: _____
Park Permission Slip continued…
On occasion we do have off-premises outings; such as, swimming, movies, ice cream, Roadside America, etc. These outings may be an out of pocket expense. You will be notified in advance of these outings. Does your child have permission to attend these outings?
YesNo
I/we, the parents/guardians of the above child, hereby give approval to participate in all activities during the current season. I/we assume all risks and hazards incidental to such participation including transportation to and from. I/we hereby waive, release, absolve, indemnity agree to hold harmless Upper Bern Township, the organizers, sponsors, leaders and persons transporting my/our children except to the extent and in the amount covered by accident or liability insurance. My/our child agrees to follow the rules of conduct set forth by the Township. I/we understand that violation of these rules can be grounds for loss of playground privileges.
Parents’ Signature: ______Date:______
See other side…