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RANDALL’S ISLAND SUMMER CAMP 2016

NAME OF HOME (CBO) AGENCY _________________________________________ 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 9/2016) ____________ 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 ____________________________________________________________

FORM # 2

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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 __ Tennis __ Horseback ___ Volleyball __ Kickball ___ Lacrosse ___ Softball ___ Nature ____ Physical Fitness ____ Wiffleball ____ Track &Field ___ Disc Activities _____Golf ___Mini Golf ___ Soccer ___ Dance ____Percussion ___ Rugby______ Self Defense_____ Bike NY_____ Capoeira ____ Urban Farm____ Waiver Release and Waiver: I hereby release and hold harmless Randall’s Island Park Alliance, Inc. (RIPA), and the New York City Department of Parks & Recreation (Parks), 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 at Randall’s Island Park. Indemnity: I will indemnify RIPA and Parks for any damage caused or liability incurred by my child during his/her visit to Randall’s Island Park. Photographic Release: I understand that my child’s photograph may be taken during camp and hereby allow RIPA staff to take photographs, videos and/or audio recordings, which contain images of my child. I understand that these images may be used by RIPA, 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. Parent/Guardian’s Signature______________________________ Date _________________ CBO Directors and parents please note: • Participants are required to provide their own lunch and transportation each day. • Participants must provide certification that current physicals have been obtained. • All campers must have medical clearance to attend Randall’s Island Summer Camp.