July 5th through August 11 th for children entering K-7 th grade

Child’s Name: DOB: Address: ______________ Grade (Fall 2023) Mother's Name: Cell #:( Email: _________________________ Father's Name: Cell #:( Email: _________________

EMERGENCY CONTACT INFORMATION: Name: Phone: __________________________________________________________________

PICK UP ALTERNATES (Emergency contacts do not have to be listed again)

Name Cell Number __________________

Name Cell Number _______________________________________________________________ HEALTH INFORMATION: *COPY OF IMMUNIZATION RECORD MUST ACCOMPANY THIS FORM * Check which apply Asthma ___ Allergies _____ ADHD _____ Diabetes ______ Seizures _____ Other issues/notes:_______________

RELEASE AND HOLD HARMLESS: By signing below the participant assume any and all risk of injury associated with the participation in the named event, and herby holds the Town of Kinderhook, its agents, employees and assigns, harmless of and from any claim, cause of action and/or lawsuit related to the participation in such event. I hereby wish for my child to participate TOWN OF KINDERHOOK SUMMER PLAYGROUND PROGRAM 2023

Signature of participant or parent


Cost: $150- 6 WEEKS OR $35 PER WEEK PLEASE MAKE CHECK PAYABLE TO: TOWN OF KINDERHOOK FORMS WILL NOT BE CONSIDERED COMPLETE UNTIL REGISTRATION FORM, IMMUNIZATION FORMS AND PAYMENTS ARE SUBMITTED. AS PROGRAM FILLS UP, ALL REGISTRATION FORMS WITHOUT ALL FORMS WILL BE PLACED ONTO THE WAITING LIST. MAIL forms to: Barbara Berger, TOK Recreation Commission, PO Box P, Niverville, NY 12130. IN PERSON REGISTRATION will be held at the Town Hall, Church Street, Valatie on March 13th and March 27th , between 6 — 7 pm. For more information contact Barbara Berger at This email address is being protected from spambots. You need JavaScript enabled to view it. Paid $ Date Cash Check # Other