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701 Saxon Avenue, Spartanburg, SC 29301 ... performed for my child by a licensed physician or hospital selected by the City of Spartanburg when deemed  ...
City of Spartanburg Parks and Recreation Department SUMMER CAMP REGISTRATION PACKET *Reminder* Registration will not be complete until you provide a copy of the youth’s birth certificate and pay any applicable fees. If you have any questions please contact Markishia Blair at [email protected] or (864) 596-3946 Northwest Center- Summer Camp for youth 5-12 years old 701 Saxon Avenue, Spartanburg, SC 29301 CC Woodson Center- Summer Camp for youth 5-12 years old 210 Bomar Avenue, Spartanburg, SC 29306 Thorton Activity Center- Summer Camp for Teens 500 Highland Street, Spartanburg, SC 29306

City of Spartanburg Program Registration $40 Registration Fee/ City Resident/ Dist. 7 Schools $50 Registration Fee/Non City Resident & All other School Dist. No Fee if being referred through Mary Black Foundation Referral Site Participant Name: (First)_________________________________ ( L a s t )

_

Age: _______ Date of Birth: _______________ School/Grade: Copy of Birth Certificate: Yes

_

No

Medical Conditions/Special Needs:

(In an effort to better serve you please acknowledge if your child has any special needs) For Parent or Guardian Name: (First)

(Last)

Address: __________________________________________ Phone: (h)

(w)

_

City:

State:

_

(c)

Email address of parent or guardian (if available): Emergency contact other than parent or guardian: Phone: (h)_______________________________ (w) Relationship to participant:

Zip:

_

(c)

_ _

AUTHORIZATIONS and RELEASE: Photograph Permission: I give permission for the City of Spartanburg to use any likeness of my child for future promotional purposes. Medical Treatment: I hereby give permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a staff member in the event I cannot be contacted. I also give permission for elected staff members to administer prescribed oral medication (including Epi-Pen injections) to my child (ren), once I (parent/guardian) have read and signed the Medial Authorization Form. I also give permission for my child to be transported by ambulance to an emergency center for treatment. I further consent to the disclosure of health information and to the medical, surgical, and hospital care treatment and procedures (including, but not limited to, administration of necessary anesthetics, tests, x-ray examinations, transfusions, injections, and drugs) to be performed for my child by a licensed physician or hospital selected by the City of Spartanburg when deemed immediately necessary or advisable by the physician to safeguard my child’s health. Release from Liability: Recognizing the City of Spartanburg will do its best to ensure a safe experience, I understand that accidents may occur both from my child's participation in youth activities and from transportation to and from the programs/events. I agree to assume these risks. By signing below, I hereby release the City of Spartanburg and their agents, officers, participants, consultants, employees and all persons and entities connected therewith (collectively the “Released Parties”) from any injury, even death, that my minor child (ren) (and all others) may sustain even if liability arises out of the negligence of the Released Parties. I have read and understand the above and agree to its contents.

Name of parent or legal guardian (print):

Date: ________________

Signature of parent or legal guardian:

Date: ________________

If signed in the presence of a City employee: Witness Signatures: __________________________________________________________ Witness Signatures: __________________________________________________________ If not signed in the presence of a City employee:

Notary Public for South Carolina: ___________________________ Notary Seal Affixed: My Commission Expires: _____________________________ (Notary seal is not required if signature is rendered in the presence of a City of Spartanburg employee).

Register at the C. C. Woodson Community Center or Northwest Recreation Center

Parks and Recreation ....Creating community through people, parks and programs!

City of SPARTANBURG South Carolina

City of Spartanburg – Parks & Recreation – 100 N. Liberty St. – Spartanburg, South Carolina – (864) 596-3105

Authorized Liability Waiver Activity: ___________________________________________ Date: ________________ Location: _______________________________________________________________ Event Organizer: _________________________________________________________ Medical Treatment: I hereby give permission for my child to be given Cardiopulmonary Resuscitation (CPR), First Aid treatment, EPI Pen injection or oral medication by staff member in the event I cannot be contacted (Release to Dispense Medicine Form must be completed). Staff will not be allowed to administer any other forms of medication outside of the above listed. I also give permission for my child to be transported by ambulance to an emergency center for treatment. I further consent to the disclosure of health information and to the medical, surgical, and hospital care treatment and procedures (including, but not limited to, administration of necessary anesthetics, tests, x-ray examinations, transfusions, injections, and drugs) to be performed for my child by a licensed physician or hospital selected by the City of Spartanburg when deemed immediately necessary or advisable by the physician to safeguard my child’s health. Release from Liability: Recognizing the City of Spartanburg will do its best to ensure a safe experience, I understand that accidents may occur both from my child's participation i n activities and from transportation to and from programs. I agree to assume these risks. By signing below, and I hereby release the City of Spartanburg and their agents, officers, participants, consultants, employees and all persons and entities connected therewith (collectively the “Released Parties”) from any injury, even death, that my minor child (ren) (and all others) may sustain even if liability arises out of the negligence of the Released Parties.

Participants Name (print): ____________________________________________ Address: __________________________________________________________ Parent/Guardian Name (print): _________________________________________ Address: __________________________________________________________ Phone Number: (H) _______________________ (C) ________________________

Allergies: ___________________________________________________________ Medication: __________________________________________________________________ Physical Limitations: ___________________________________________________________ Name of Insurance: ________________________________Policy#: ______________________

__________________________________________________ Participants Signature (non-minor)

_______________ Date

___________________________________________________ Parent/Guardian Signature

______________ Date

If signed in the presence of a City employee: Witness Signatures: __________________________________________________________ Witness Signatures: __________________________________________________________ If not signed in the presence of a City employee: Notary Public for South Carolina: ___________________________ Notary Seal Affixed: My Commission Expires: _____________________________ (Notary seal is not required if signature is rendered in the presence of a City of Spartanburg employee). Register at the C. C. Woodson Community Center or Northwest Recreation Center

City of SPARTANBURG South Carolina MINOR - AUTHORIZED PASSENGER LIABILITY WAIVER FORM My child ___________________________________ Age______, will be traveling as an authorized passenger, in a vehicle owned/provided by the City of Spartanburg, traveling from __________________________________ to __________________________________ on the date(s) of _________________________, _

_ to ______________________,

. I hereby

waive any right to make a claim against the City of Spartanburg. Therefore I hereby assume all the risks described above and hereby release the City of Spartanburg and their agents, officers, participants, consultants, employees and all persons and entities connected therewith (collectively the “Released Parties”) from any injury, even death, my minor child (ren) (and all others) may sustain even if liability arises out of the negligence of the Released Parties. Parent/Guardian Name: ___________________________________________________ Address: _______________________________________________________________ City, State & Zip Code: ___________________________________________________ Phone No.: _______________________ IF AUTHORIZED PASSENGER IS UNDER AGE 18, SIGNATURE OF PARENT OR GUARDIAN IS MANDATORY AND SIGNATURE MUST BE WITNESSED (in the presence of a City employee) or NOTARIZED BY A NOTARY PUBLIC (if not signed in the presence of a City employee).

Parent or Guardian’s Signature: ___________________________________________ Emergency contact other than parent or guardian Phone: (h) ___________________ (w) ________________(c) _______________ Relationship to participant: __________________________________________ If signed in the presence of a City employee: Witness Signatures: __________________________________________________________ Witness Signatures __________________________________________________________ If not signed in the presence of a City employee:

Notary Public for South Carolina: ___________________________ Notary Seal Affixed: My Commission Expires: _____________________________ (Notary seal is not required if signature is rendered in the presence of a City of Spartanburg employee).

Daily Medication Sign In/Out Camper Name: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Notes:

Medication:

Reason for Medication:

Date: Counselor Responsible:

Received by Counselor:

Returned by Counselor:

City of Spartanburg Medical Emergency Action Plan

Name of Participant:

Age:

__ Grade:

Parent/Guardian’s Name (s): Primary Contact Number:

Secondary Contact Number:

Participants Medical Condition (parent/guardian to complete):

_ Participant’s history with condition, including know triggers (parent/guardian to complete): *PLEASE BE SPECIFIC*

Preventative steps to be taken by Camp Staff (staff and parent/guardian to complete together): 1. 2. 3. 4. 5. A medical emergency would include the following signs and/or symptoms (parent/guardian to complete): • • • • In the event of a medical emergency the following steps will be taken by City of Spartanburg Staff. 1. 2. 3. 4. Any additional notes:

Signature of Parent/Guardian

Date

Signature of Summer Program Director

Date

Summer Recreational Swim Program

Child Name: (First) _________________________________ (Last) Age: _________ Date of Birth:

School /Grade:

Medical Conditions: ____________________________________________________________________________ Special Needs: (In an effort to better serve you please acknowledge if your child has any special needs) For Parent or Guardian Name: (First) (Last) Address: City: Phone: (h) (w) Email address of parent or guardian (if available)

_

_ State:

Zip: (c)

Emergency contact other than parent or guardian Name: (First) ______________________________ (Last)________________________________ Phone: (h) _________________________ (w) (c) Relationship to participant:

_

AUTHORIZATIONS and RELEASE: Photograph Permission: I give permission for the City of Spartanburg to use any likeness of my child for future promotional purposes. Medical Treatment: I hereby give permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a qualified staff member in the event I cannot be contacted, I also give permission for my child to be transported by ambulance to an emergency center for treatment. I further consent to the disclosure of health information and to the medical, surgical, and hospital care treatment and procedures (including, but not limited to, administration of necessary anesthetics, tests, x-ray examinations, transfusions, injections, and drugs) to be performed for my child by a licensed physician or hospital selected by the City of Spartanburg when deemed immediately necessary or advisable by the physician to safeguard my child’s health I acknowledge that I am the parent or legal guardian of the above named child. I give my permission for this child to participate in the CC Woodson's summer recreational swim program. I further understand that any fighting, destruction of property, disrespect or failure to follow the rules of the CC Woodson's Swim Zone a n d City of Spartanburg S t a f f may result to your child being expelled from participation in this summer program. Participants must wear proper swimsuits to be admitted to the pool. Boys must have a liner and a draw string in the swim trunks, basketball shorts are not permitted. Girls must have a lycra based swimsuit. All swimsuits must cover the body appropriately. I hereby waive any right to make a claim against the City of Spartanburg, Therefore I hereby assume all the risks described above and hereby release the City of Spartanburg and their agents, officers, participants, consultants, employees and all persons and entities connected therewith (collectively the “Released Parties”) from any injury, even death, that my minor child (ren) (and all others) may sustain even if liability arises out of the negligence of the Released Parties.

For more information please contact The CC Woodson Recreation Center 596-3710 or via email: [email protected] City of Spartanburg - Parks & Recreation - 100 N. Liberty St. - P.O. Box 1749 - Spartanburg, South Carolina - www.cityofspartanburg.org

I have read and understand the above and agree to its contents.

Name of parent or legal guardian (print):

Date:

Signature of parent or legal guardian:

Date: __________________

If signed in the presence of a City employee: Witness Signatures: __________________________________________________________ Witness Signatures: __________________________________________________________ If not signed in the presence of a City employee:

Notary Public for South Carolina: ___________________________ Notary Seal Affixed: My Commission Expires: _____________________________ (Notary seal is not required if signature is rendered in the presence of a City of Spartanburg employee).

Register at the C. C. Woodson Community Center or Northwest Recreation Center

For more information please contact The CC Woodson Recreation Center 596-3710 or via email: [email protected] City of Spartanburg - Parks & Recreation - 100 N. Liberty St. - P.O. Box 1749 - Spartanburg, South Carolina - www.cityofspartanburg.org

City of Spartanburg Parks and Recreation Pick-up Disclaimer

Childs Name: __________________________ Childs Name: __________________________ Childs Name: __________________________ Childs Name: __________________________ Childs Name: __________________________

DOB: ________________________ DOB: ________________________ DOB: ________________________ DOB: ________________________ DOB: ________________________

Authorized Parent/Guardian: __________________________________________ Phone: (h) __________________

(c) ____________________ (w) _______________

The following individuals have permission to pick up my child (name & relationship to child) 1.

Name ____________________ Relationship to child _____________ (P) ___________ (phone)

2. Name ____________________ Relationship to child _____________ (P) ___________ (phone)

3. Name ____________________ Relationship to child _____________ (P) ___________ (phone)

(Individuals not listed will not be allowed to pick up child (ren) regardless of circumstances) ***Employees!! PLEASE ASK FOR ID*** By signing this agreement is an acknowledgement of this policy Parent/Guardian Name (print): ________________________________________ Parent/Guardian Signature: __________________________________________ Date: __________________, Witness Signature: ______________________________

City of

SPARTANBURG The City of Spartanburg Waiver and Permission to Walk Home Child Name: ________________________________ DOB: _________________________ Child Name: ________________________________ DOB: _________________________ Child Name: ________________________________ DOB: _________________________ Child Name: ________________________________ DOB: _________________________ Parent/Legal Guardian Name: _________________________________________________ Print Name Phone: (h) _____________________ (w) ______________________ (c) _________________ It is the general policy of The City of Spartanburg that all students are to be picked up at the completion of the City’s programmed activity or event by an authorized adult. The authorized person must sign out the registered child. However, there are circumstances in which a parent/guardian prefers to give permission for his/her child to walk home/ o r leave the program without adult supervision. The purpose of this waiver/permission slip is to give permission for your child to walk home from the City’s Park & Recreation programmed activity or event. By signing below, I hereby give permission for the above named child (ren) to walk home from the City’s Park & Recreation programmed activity or event without adult supervision on any day the program is being held and my child is present. Release from Liability: Recognizing the City of Spartanburg will do its best to ensure a safe experience, I understand that accidents may occur from my child’s participation in walking home from programmed activities or events. By my signature below, I release the City of Spartanburg and its agents from any and all liability based on any damage and loss or injury (including death), whether it is the result of negligence or otherwise, caused to my child or to me, which may arise out of my child (ren) w al k i n g h o m e af t e r t he p r o g r am m e d a c t i vi t i e s o r e v e n t without adult sign out or adult supervision.

Parent/ Legal Guardian Signature

Date

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