Camper Full Name ______________________________________________________ Age (as of 7/5/10) ______

       2010 TOWN OF GARDINER SUMMER RECREATION PROGRAM

DATES:             Monday, July 5^th – Friday, August 13, 2010

TIME:                9:00 a.m. – 3:00 p.m. Monday – Friday

PLACE:             George Majestic Memorial Park, Murphy Lane

AGES:                5 to 13; Child(ren) must be registered for Kindergarten in September 2010 (School Age)

                             (There are a limited number of Counselor-In-Training Positions available

                                   for 14 – 15 year olds – Please inquire at registration for details)

 SIGN-UP:        BRING REGISTRATION FORM, FULL PAYMENT (CASH OR CHECK ONLY)

                           IMMUNIZATION RECORDS & PROOF OF RESIDENCY TO GARDINER TOWN HALL.

                             For Gardiner Residents Only:           Friday, April 23, 2010 – 4:00 – 6:00 pm.

                             For Gardiner Residents Only:           Saturday April 24, 2010 – 11:00 am – 1:00 pm.

                             Open Sign-Up (Non-Residents):         Friday, April 30, 2010 – 4:00 – 6:00 pm.

                             Open Sign-Up (Non-Residents):         Saturday May 1, 2010 – 11:00 am – 1:00 pm.

***PLEASE NOTE: ALL GARDINER RESIDENTS WILL HAVE PREFERENCE***

FEES: $350 for first child from each Gardiner family                          Fees include pool admission and

           $325 for each additional child of Gardiner residents                   camp t-shirt. However, each camper is

           $400 for non-residents                                                                 responsible for the cost of admission,                                                                                                 refreshments, etc. at each field trip.

PARENT'S LAST NAME: _______________________________________ FIRST: _______________________

HOME ADDRESS: ___________________________________________________________________________

MAILING ADDRESS: _________________________________________________________________________

HOME # ______________________ CELL # ________________________WORK # ______________________

IN EMERGENCY, CONTACT: __________________________________ TEL # ________________________

NAME OF CHILD (If you have more than one child attending camp, please complete separate form for each):

_______________________________________  (M/F) AGE: _____ DOB: _____________ Entering ____ grade

ETHNICITY (OPTIONAL)  ___ Caucasian   ___ African-American   ___ Latino    ___ Asian     ___ Native American     Other _________

OTHER CAMPER(S) REQUESTED IN CHILD'S GROUP? ___________________________________________

_____________________________________________________________________________________________

COUNSELOR(S) REQUESTED? _________________________________________________________________

Does child have allergies or any mental/physical condition which we should be aware of    (   ) NO    (   ) YES,

Explain: _____________________________________________________________________________________

GARDINER RESIDENT  (YES / NO)                                                                    FEE ENCLOSED:   $__________

PARENT'S SIGNATURE: ________________________________________  DATE: _______________________

**********IMPORTANT: You must complete the attached immunization forms for each child.***********

                                       IMMUNIZATION                                               DATE

DPT ______________________________________________ 1^st   __________________

DPT ______________________________________________ 2^nd  __________________

DPT ______________________________________________ 3^rd   __________________

DPT ______________________________________________ 4^th   __________________

DPT ______________________________________________ 5^th  __________________

MMR _____________________________________________ 1^st __________________

MMR _____________________________________________ 2^nd __________________

POLIO ____________________________________________ 1^st __________________

POLIO ____________________________________________ 2^nd__________________

POLIO ____________________________________________ 3^rd__________________

POLIO ____________________________________________ 4^th__________________

HEPATITIS B SERIES _______________________________ 1^st __________________

HEPATITIS B SERIES ______________________________   2^nd___________________

HEPATITIS B SERIES _______________________________ 3^rd__________________

HEPATITIS B SERIES _______________________________ 4^th__________________

HAEMOPHILUS INFLUENZA TYPE B ______________________________________

VARICELLA (chicken pox)  ________________________________________________

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

In case of emergency, contact: ____________________________________________________

Relationship: _________________________    Phone #: _______________________________

Name of Physician: _______________________________ Phone # _______________________

If necessary, please transport my child to _____________________________________ hospital

by Gardiner Fire Department Rescue Squad or other emergency service: 

Sign Here: ________________________________Relationship: ___________ Date: _________