R e g i s t r at i o n f o r m

For Office Use Only:

PLEASE MAKE CHECKS PAYABLE TO TOWN OF STOWE, AND MAIL TO:

Date Paid:_______________
Date Entered:____________
By Whom:______________

Stowe Parks and Recreation Department

P.O. Box 730
Stowe, VT 05672

Participant/Applicant__________________________________ Date of Birth_________ Age ______

F Grade ______

Parent(s) Name(s)____________________________________________________________________________________________
Mailing Address: PO Box/Street____________________________________Town_________________State______Zip__________
Residence:Street & Number_______________________________________Town_________________State______Zip__________
Home Phone:___________________________Work Phone:___________________________Email:_________________________
Emergency Contact Name:________________________________________Emergency Contact Phone #____________________
List all allergies or physical difficulties that the Staff should be aware of: _____________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Waiver Agreement:

I am fully aware that there are risks of physical injury in participating in sports and recreational
activities and hereby give my consent for the named applicant to participate in the program(s) offered by Stowe Parks and
Recreation. I hereby knowingly and fully release and hold harmless the Town of Stowe, its employees, elected officials, any
volunteers, instructors or sub- contractors from any and all liability from injury claims, costs, loss of services, damages or loss
of personal property in the said programs, activities or events. I certify that my child/participant is in excellent health and that
there are no limitations to his/her participation except as stated in writing above. Furthermore, in the event of an emergency,
accident, injury, or illness and if reasonable effort to contact me has failed, I hereby give the designated emergency contact
permission to act as my childs(rens) temporary guardian. In the event of an accident, injury, or illness and if reasonable effort
to contact me has failed, I hereby give attending physicians or authorized medical personnel consent and permission to provide
my child/participant with any necessary medical treatment, including x-rays and medication.
_________________________________________________________
Parent or Legal Guardian Signature/Date

Photo Permission:

From time to time photographs will be taken to be used in our publications. Do you give the Stowe Parks and Recreation
Department permission to use yours and/or your childs photograph?
YES
NO

Please fill in the program(s) the Participant is registering for:

Program Number

Program Name

Some youth sports programs require uniforms.

Shirt Size_______(ys / ym / yl / as / am / al / axl / axxl)

____ Visa

____ MasterCard

Credit Card*

Debit Card

Session Date and/or Time

Fee

Scholarship Donation (of at least $1.00)

TOTAL

____ Discover

Name (as it appears on card) ___________________________________________

#__________________________________ Exp Date __________ 3-digit Security Code (on back of card)____________

*The Town of Stowe is authorized to a 3% convenience charge for the use of credit cards

One form per child must be filled out by a parent or guardian and returned to the Recreation Office.
Childs Name: _________________________________
Authorized to Pick Up:

(People authorized to pick up my child from camp, other than parents)

NAME
1.___________________________
2.___________________________
3.___________________________

RELATIONSHIP
_________________________
_________________________
_________________________

Swim Level of your child (circle one):

Non-Swimmer

Beginner

PHONE #
__________________
__________________
__________________
Intermediate

Advanced

Describe any water fears or cautions we should know ________________________________________________

My Child MUST wear a floatation device at all times when swimming
Emergency Contact:

Yes

No

(This must be someone other than the parents, and will be used if neither parent can be reached)

Contact Name: ________________________________________

Home Phone: _________________________

Relationship: ____________________________

Work Phone: ___________________

Cell Phone: ________________

Address: __________________________________________________________________________________________
(Street Address)

(City)

(State)

(Zip)

Health History:
Medication: Please list the medications that your child is required to take daily: ____________________________
1.) Will any of these medications need to be administered to your child during camp?

Yes

No

(If yes, you must fill out the Medication Authorization Form, and bring to camp on the first day with medication)

Allergies:

2.) Is your child required to carry an epinephrine pen with them at all times?

Yes

No

1.) Does your child have any allergies to food, medication or the environment?

Yes

No

(If yes, please describe in detail the allergies, reaction and the management or care needed)

Allergies
_____________________________
_____________________________
Medical Conditions:

Reaction
_______________________
_______________________

Management and Care

________________________________
________________________________

1.) Does your child have any Medical Conditions that we need to be aware of?

Yes

No

(If yes, please describe in detail the condition, symptoms, and the management or care needed)

Medical Condition
______________________________
______________________________

Symptoms
________________________
________________________

Management and Care

________________________________
________________________________

Sunscreen/Insect Repellent:
____YES- I give permission for the Stowe Parks & Recreation staff/employees to apply sunscreen and/or insect repellant to my
child, for the 2015 summer season.
____ NO - I do not give permission for sunscreen or insect repellent to be applied to my child. We will do it at home.

Please provide any additional information about your childs behavior, and/or physical,
emotional or mental health concerns that the camp staff should be aware of: ___________________________________
________________________________________________________________________________________________

Additional Information:

I attest the information above is correct and complete to the best of my knowledge. I hereby agree to the release of any information for the
knowledge of Stowe Parks & Recreation staff, necessary treatment, and give my child the proper medication and/or grant them the permissions as
stated.
Signature of Parent/Guardian _________________________________________________

Date: ________________________________

Camp Directors will NOT give medication to any child until this form is completed and returned to them or the Recreation Office.
Please carefully read the instructions below. If these procedures are not followed we will not be able to administer any medication
to your child.

Prescribed Medication:
1.
2.

3.

We must receive any prescribed medication in its original packaging and/or bottle with your childs name on it.
It must identify the prescribing physician, the name of the medication, the dosage, and the frequency of administration.
All information on the bottle must also match the information you fill out on the Medication Authorization Form. Place
this form and medication in a zip lock bag and give to the Camp Director .

Non-Prescribed Medication:
1.
2.

Must be received in original packaging and/or bottle.

Parents must write out the dosage and frequency of administration below and place this form with original packaging in a
zip lock bag and give to the Camp Director.

Consent to Administer Medication

The Consent to Administer Medication portion of this form is good for the summer, unless there is a change in medication or
dosage. The Medication Log- has to be renewed each week that medication will be given while your child is at camp. You will
need to provide a new Medication Log on Mondays or the first day your child will attend camp each week with the medication.
Only send enough medication for one week.
Childs Name: _________________________________________________
Prescribing Physician ___________________________________________

Gender: M F DOB: ____/_____/_____

Office Phone # __________________________

Medication:
Medication #1 __________________________________________ Dosage _________________________________
Times to be administered: __________________________
Refrigerate:
Yes____ No _____
Side Effects ________________________________________________________________________________
Stop Medication if the following reactions occur: __________________________________________________
Medication #2 __________________________________________ Dosage _________________________________
Times to be administered: __________________________
Refrigerate:
Yes____ No _____
Side Effects ________________________________________________________________________________
Stop Medication if the following reactions occur: __________________________________________________
Medication #3 __________________________________________ Dosage _________________________________
Times to be administered: __________________________
Refrigerate:
Yes____ No _____
Side Effects ________________________________________________________________________________
Stop Medication if the following reactions occur: __________________________________________________

Medication Log
Campers Name: ______________________________________

For the week of: _________________

Consent: I hereby give permission for my child to take the below listed prescription or non-prescription medication(s), as ordered, at the Stowe Parks
& Recreation Summer Camp, I give permission for this medication to be administered by the Camp Director or his/her designee.

Signature of Parent/Guardian __________________________________________

Date: _________________________

This Section is to be filled out by the camp director each day that medication is administered:

Name of Medication

Dosage

Time Medication Given

MON

1.
2.
3.

TUES

WED

THURS

FRI

Parks & Recreation

Town of Stowe

PO Box 730
336 Park Street
Stowe, VT 05672

Behavior and Discipline Policies Agreement

1. All participants are expected to respect themselves and everyone else around them.
Be polite and considerate to others
NO FOUL LANGUAGE
No fighting/bullying
Play fairly and safely during all activities
Report any problems to the Supervisor/Counselors
2. Everyone is expected to respect the property of others, and the equipment of the Stowe
School District, along with the equipment of the Stowe Parks and Recreation Department.
No running in the halls of the school.
Use the equipment properly, take care of the equipment, and pick up things when
youre done using them.
Stay in the designated area for your program (Gym, Cafeteria, and Playground)
3. Participants are expected to show respect for the Supervisors, and any counselors that are on
duty.
No talking back when asked to do something
Always be cooperative with the counselors
4. Everyone is expected to be honest and truthful in all his or her dealings.
5. All participants should have sneakers to wear in the gym.
6. Everyone will abide by any other rule that may come up when asked to do so.
7. Any physical contact, with the intent to hurt another individual will not be tolerated.
(Child will be asked to leave the program).
Discipline
Each case will be looked at on individual basis. All behavior incidents will be documented.
Standard Procedures
1st time: Verbal Warning
2nd time: Time Away from activity, camp director is notified.
3rd time: Time Away from activity, child is sent home.
4th time: Parent is called, child is sent home and may be dismissed for the program (last resort)

______________________________
Parent/Guardian Signature

Tel: (802) 253-6138

Email: Recreation@townofstowevermont.org

___________________________
Childs Signature

Fax: (802) 253-3723 Website: www.StoweRec.org