Town of Owego Summer Camp Registration

Please fill out a separate form for each child.

Child’s Name _______________________ Age ___ Date of Birth _________ M/ F

Address ________________________ City________________ State_____ ZIP ______

Telephone__________________________ Cell Phone _________________________

Name(s) of Parent/Guardian __________________________________________

Work Phone(s) ____________________ Email Address _________________________

Please circle weeks child will attend:

1. (7/5-9) 2. (7/12-16) 3. (7/19-23) 4. (7/26-30) 5. (8/2-6)

Please provide an alternative contact in the event you cannot be reached.

Name:___________________________ Phone:____________________________

Medical Information* Please fill in all lines on form.

Allergies? Yes/No (please circle) If yes, please list ____________________________

Medications? Yes/No (please circle) If yes, please list ____________________________

Please list any medical conditions including ADHD or any other behavioral conditions within the last 3 years:(write none if no conditions exist) ___________________________________________________________ __________

Please attach immunization records for the following: MMR, DPT, Polio, Tetanus, Hep B, HIB and Varicella (Chicken Pox).

Doctor’s Name_______________________Doctor’s Phone _______________________

Insurance Name & Policy __________________________________________________

*This information is required by NYS law and Tioga County Health Dept.

I give my permission for __________________________________________

to take part in the Town of Owego Summer Recreation Camp provided by Waterman Conservation Education Center. This child, to the best of my knowledge, is in good physical condition and is capable of outdoor physical activities. I understand that outdoor activities have an inherent risk factor. I give permission to the Waterman staff and volunteers and/or hospitals to administer proper medical assistance to the above named participant. I agree not to hold the Fred L. Waterman Conservation Education Center, Inc. or any of their agents responsible in the event of injury.

Parent/Guardian (Please Print) ____________________ Signature ____________________Date______

Return with immunization record to: Waterman Center 403 Hilton Road Apalachin, NY 13732

Office Use Only Checked by ______________ Date____________ Comment______________________________