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2010 REGISTRATION FORMBOYS & GIRLS GRADES K-8
This is a full day program for children entering grades K-8. The
program will run on non-major holiday days the schools are closed.
. Program hours wrom 8:30 am to 4:30 pm. Pre-program hours will be
available from 7:00 am to 8:15 am and after program hours runs from
4:30 pm to 6:30 daily. Uoted on the schedule or other program
documents, all program activities will take place at the Ewing
Senior & Community Center, 999 Lower Ferry
Ewing New Jersey 08628 & Hollowbrook Community Center 320
Hollowbrook Dr Ewing NJ 08638.
Cost: Ewing Residents $40 per day per child Non-residents $45
per day per childMultiple child discount: Residents- 2nd child $30
3rd child $20 Non-residents 2nd child $40 3rd child $35
Registration Deadline: 1 week prior to day registering for is
preferred
Registration: Completed forms will be accepted at the Ewing
Recreation Department located at 999 Lower Ferry Road, Ewing, NJ.
Office hours are 9:3o 4:30 pm. Completed forms can be mailed to the
Recreation Department, 999 Lower Ferry Road, Ewing, NJ 08628.
taff: Program Director is Jessica Stephens. Jessica worked at
this camp location for the 2010 Summer Day Camp. She is a Ewing
Resident and workLore School for 4 years. Other staff members
include teachers, college students and high school students.
Child Information Grade entering in 9/10
__________________________________ Date:
________________________________________________
irst Name _______________________________________________ Last
Name ______________________________________________________PRINT
NAME CLEARLY
Address
_____________________________________________________________ City
__________________ State __________ Zip____________
chool - 9/10
_____________________________________________________________________
Gender _______________
pecial Needs Child __________ Yes __________ No
es__________________________________________________________________________
Parent or Guardian
Information________________________________________________________________________________________________
Phone (home) ________________________________________ (cell)
___________________________ e-mail
_______________________________
Your child must be picked up from the program or after-program.
Please list people responsible for picking up your child, including
parent
iblings.
________________________________________ 2.
________________________________________ 3
______________________________________
Check Location: Ewing Community Center________ Hollowbrook
Community Center______
PLEASE CHECK THE DATE/S CHILD IS REGISTERING FOR
RESIDENTS - $40/FULL DAY $20/HALF DAY NON-RESIDENTS - $45/FULL
DAY $22.50/HALF DAYMULTIPLE CHILD DISCOUNT RESIDENTS 1ST CHILD $40
2ND CHILD $30 3RD CHILD $20
MULTIPLE CHILD DISCOUNT NON-RESIDENTS 1ST CHILD $45 2ND CHILD
$40 3RD CHILD $35eptember November December January April
April_______9th (Escc Only) _______1st ________8th ______14th
_____18th _____25th
October _______2nd ________23rd (half day) ______17th _____19th
_____26th_______5th _______4th & 5th ________27th ______ 31st
_____20th _____27th_______8th _______18th (half day) ________28th
_____21st _____28th_______11th _______19th (half day) ________29th
February _____22nd _____29th_______15th _______22nd (half day)
________30th _______3rd (half day)
_______23rd (half day) ________31st _______18th_______24th (half
day) _______21st
_______26th Before Care Program 7-8:15___________ After Care
Program4:30-6:30____________***************************************************************************************************************************
OFFICE USE ONLY Make checks payable to EWING RECREATION
DEPARTMENT
Amount Paid: $_____________________________ Cash:
$___________________ Check # _____________________
Full:____________
eceived by: ________________________________ Date:
_____________________ Receipt # ____________________
Partial:__________
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ACKNOWLEDGMENT OF RISK
Program: Ewing Recreation Schools Closed Program , Pre-Program
and After-Program
I am aware that participating in this activity can be dangerous
and involves risk of injury. I realize thaparticipation in the
above-mentioned activity presents risk, which includes minor or
serious injury to any part ofthe body. These injuries could lead to
temporary or permanent disability or even death.
While the possibility of serious injury to participants is
unlikely, it is important that all participants andparents realize
that these risks do exist.
PARENT/GUARDIAN AGREEMENT
I also recognize and acknowledge that there are certain risks of
physical injury inherent in the namedminors participation in this
program. I have received, read and understand the risks and have
discussed themwith my child. He/she understands that he/she must
obey all rules and regulations follow all safety proceduresand obey
any and all instructors, assistant instructors and staff members
assigned to the program. My child andI understand the risk
associated with this program, and my child and I agreed to accept
our responsibility in
making this program a safe one.
I certify that the minor is in proper physical condition for
safe participation in the Ewing RecreationSchools Closed Program
and I agree that it is incumbent upon me to immediately inform the
Ewing RecreationSchools Closed Program Director should the minors
physical condition change at any time prior to or duringhis/her
participation in the program.
I expressly agree that this agreement is intended to be as broad
and inclusive as permitted by the Lawsof the State of New Jersey
and that if any portion of the agreement is held invalid, it is
agreed that the balanceshall continue in full legal force and
effect and be valid.
In consideration of the Ewing Recreation Department permitting
the name minor to participate in theRecreation Department
previously mentioned, the undersigned, being the parent(s) or legal
guardian of____________________________________________________
hereby waive and relinquish all claims I (we)may have as a result
of said minor participating in the program against the Ewing
Township RecreationCommission, Ewing Township Recreation Department
and Ewing Township Mayor and Council, its offices,agents, servants
and employees from any and all claims for injuries including death,
damage or loss of propertywhich may accrue to us on account of the
minors participation in said program and we further agree to
holdharmless the Ewing Township Recreation Commission, Ewing
Recreation Department and Ewing TownshipMayor and Council, its
officers, agents, servants, and employees from any and all such
claims.
Parent or Legal Guardian [indicate which]
_________________________________________________________________________________SIGNATURE
_________________________________________________
_________________________________________________________________________________DATE
PRINT NAME
