KDDBIZ2000 SUMMER DAY CAMP 2019
Dover New Delaware 19901
Where Kids Have Fun, Share, Inspire And Learn
Camper Registration Form (to be completed by campers and parents)
NAME ____________________________________________________________________
PARENT/GUARDIAN _______________________________________________________
STREET ____________________________ APT. ____ BOROUGH ______ ZIP ________
PHONE _____________________________ DATE OF BIRTH ______________________
EMERGENCY CONTACT ____________________________ PHONE ________________
ADDRESS _________________________________________ PHONE ________________
SCHOOL ____________________________________ GRADE (as of 9/14) ____________
ADDRESS _________________________________________ PHONE ________________
HEALTH
Are you in good health? YES ______ NO ______
Are you asthmatic? YES ______ NO _______
Do you take any medication? YES _____ NO _____ Name of medication ________
Do you have any known allergies? YES _____ NO _____ If yes please explain ___
____________________________________________________________________
INSURANCE
Does your family have medical insurance? YES _____ NO _____
Health insurance carrier ____________________________ Policy # ____________
Have you suffered any injuries or had any health problems in the last 6 months?
YES ___NO_____Describe______________________________________________________
ACTIVITY SELECTION (campers will be rotated throughout all activities, however, we will try to honor your choices whenever possible)
(1 for the first choice, 2 for the second, 3 for the third)
Basketball __ Horseback ___ Volleyball __ Kickball ___ Biking___
Softball ___ Nature Hunt ____ Physical Fitness ____ Volleyball ____
Tug A War___ Track &Field ___Natural Gardening___ Cooking Is Fun____
Bird Watching____ Bowling _____Mini Golf ___ Soccer ___
Dance_____Swimming______Water Park Activities_____ Bike NY_____
Arts &; Crafts ____ Urban Farm____
Release and Waiver: I hereby release and hold harmless KDDBIZ2000 Enrichment Program, Inc. (KBEP)
including successors, assigns, officers, directors and employees and all related parties contracted by the aforementioned of any and all liability, claims, and demands of whatever kind or nature, which arise or may hereafter arise from any harm to my child suffered during or as a result of his/her participation in camp or transportation to camp. I further acknowledge and agree that there are certain inherent dangers in playing sports and that neither RIPA shall be liable for any personal injuries, property damage, or other loss sustained by the undersigned or by my child in, on or about Randall’s Island, or arising out of the use or intended use of any facilities, equipment or other property during the summer camp.
Medical Treatment: To the best of my knowledge, my child is in good physical condition and may participate safely in camp. I hereby release RIPA and Parks from any claim which arises on account of any first aid, treatment, or service rendered to my child in connection with any incident with KDDBIZ2000 Summer Day Camp.
Indemnity: I will indemnify RIPA and Parks for any damage caused or liability incurred by my child during his/her visit to KDDBIZ2000 Summer Day Camp.
Photographic Release: I understand that my child’s photograph may be taken during camp and hereby allow KBEP staff to take photographs, videos and/or audio recordings, which contain images of my child. I understand that these images may be used by KBEP, and agree to allow them to publish or reproduce such images.
Commitment: If selected for camp, my child will be committed to attending each day, unless unforeseen circumstances arise. My child will also follow the rules of camp and behave in a sportsmanship like manner at all times.
Other: I understand that this Release shall be governed by and interpreted in accordance with the laws of the State of New York. I agree that in the event that any provision of this Release shall be held to be invalid by any court, the invalidity of such provision shall not otherwise affect the remaining provisions of this Release which shall continue to be enforceable.
KBEP : guardians and parents please note:
· Participants are provided with a lite breakfast, lunch each day.
· Participants must provide proof of certification that current immunization shits and physicals have been obtained.
All children must have medical clearance to attend KDDBIZ2
Our community and their children deserve to have a summer program that is positive and both
affordable for every child in the Co-op City Community.
(No Child Left Behind) Is our motto which we stand by and many of our registered families of this
community rely on our program and the many educational enrichment programs, and adventurous activities
we offer them,.
Building strong Academic Leaders One child At A Time.
Lisa Carroll - Program Director
Kddbiz2000 Enrichment Program
