Summer Program Enrollment

Emergency Contacts

IN THE CASE OF AN EMERGENCY, LIST PEOPLE TO BE CONTACTED IF NEITHER PARENT CAN BE REACHED. * MUST BE IN ADDITION TO PARENTS OR GUARDIAN. YOUR CHILD WILL ONLY BE RELEASED TO THE INDIVIDUALS ON THIS FORM. ALL OF THE INDIVIDUALS LISTED MUST BE AT LEAST 16 YEARS OF AGE AND HAVE PHOTO IDENTIFICATION.

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Emergency Contact 1

Name

Phone #

Street Address

Address

City

Zip Code

Employer

Work #

Relationship to Child

Emergency Contact 2

Name

Phone #

Street Address

Address

City

Zip Code

Employer

Work #

Relationship to Child

Medical Information

Please list name of family doctor, hospital of choice in case of emergency, allergies, disabilities, medical conditions & health insurance information.

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Family Doctor

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Address

Phone #

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City

State

Zip

AllergiesMedications Currently TakenMedical Concerns

My Child does have a diagnosed severe developmental disability*

YES

*** If Yes, a treatment/behavioral plan must be established

A Watervliet Civic Center Staff Member has permission to apply sunscreen to my child*

YES

Hospital of Choice

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Health Insurance Company

Policy #

EACH CHILD WHO ATTENDS THE SUMMER RECREATION PROGRAM MUST HAVEAN UPDATED IMMUNIZATION RECORDS. NO CHILD WILL BE ALLOWED TOATTEND THE PROGRAM WITHOUT AN UPDATED IMMUNIZATION RECORD.

IN THE CASE OF AN EMERGENCY, I UNDERSTAND THAT EVERY EFFORT WILL BE

MADE TO CONTACT THE PARENT/GUARDIAN. IN THE EVENT, THE

PARENT/GUARDIAN CANNOT BE REACHED, THE CHILD WILL BE TRANSPORTED TO THE HOSPITAL PRE-SELECTED ON THE APPLICATION.

MY CHILD HAS PERMISSION TO ATTEND THE WATERVLIET CIVIC CENTER 2026

SUMMER RECREATION PROGRAM. HE OR SHE IS IN GOOD HEALTH AND CAN PARTICIPATE IN ALL ACTIVITIES AND EVENTS INCLUDING SWIMMING AND FIELD TRIPS.

I HAVE RECEIVED A COPY OF THE WATERVLIET CIVIC CENTER 2026 SUMMER

RECREATION PROGRAM PARENT HANDBOOK. BY SIGNING THIS APPLICATION, I ACKNOWLEDGE THAT 1 UNDERSTAND AND AGREE TO ABIDE BY THE POLICIES AND PROCEDURES CONTAINED THEREIN.

GENERAL WAIVER OF LIABILITY: MY CHILD PLANS TO PARTICIPATE IN THE WATERVLIET CIVIC CENTER 2026 SUMMER RECREATION PROGRAM, BY SIGNING THIS RELEASE AND APPLICATION FORM, I UNDERSTAND THAT THE WATERVLIET CIVIC CENTER WILL NOT BE HELD RESPONSIBLE FOR INJURY TO PERSON OR PROPERTY.

PARENT/GUARDIAN SIGNATURE:

Child & Guardian Information

Emergency Contacts

Medical Information

Session Enrollment

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