SOUTH FAYETTE TOWNSHIP SUMMER PLAYGROUND PROGRAM REGISTRATION FORM 2008
(412) 221-8700 OFFICE • (412) 221-7798 FAX

Child’s Name: ________________________ _________________________________
Last First
Age/Grade:_______/_______ Please Note – Child must be at least 5 years of age at start of program
Address: _________________________________________________________________
City: _____________________________ State:_______ Zip Code: _________________

PARENT/GUARDIAN INFORMATION
Name: ____________________________
Relationship to child:_______________
Home #:(____)_____________________
Work #: (____)_____________________
Cell #: (____)______________________
Name: ____________________________
Relationship to child:_______________
Home #:(____)____________________
Work #: (____)____________________
Cell #: (____)_____________________

EMERGENCY CONTACT
If neither parent is available in the event of an emergency, please notify:
Name: ____________________________
Relationship to child:_______________
Home #:(____)____________________
Work #: (____)____________________
Cell #: (____)_____________________
Name: ____________________________
Relationship to child:_______________
Home #:(____)_____________________
Work #: (____)_____________________
Cell #: (____)______________________

HEALTH RECORD/ALLERGIES/MEDICAL INFO.
Health Insurance Information:
Insurance Company: _______________________________________________________
Group Number: ___________________________________________________________
Identification Number: _____________________________________________________
I authorize (please select one):
Emergency medical care at the nearest medical facility
Other (specify): ___________________________________
I authorize transportation to the nearest medical facility by (select one):
Nearest emergency service vehicle
Other (specify): ___________________________________
Allergies: (please check all that apply) Insect Stings Penicillin
Foods (explain) _____________ Other_____________
Medical Information:
Current Medication(s) & Purpose:_________________________________


GENERAL INFORMATION
Registration should be ASAP. There is limited space and sessions are filled on a first-come, first-served basis. Please register as early as possible to insure placement of preferred sessions.

Registrations will not be accepted prior to Monday, May 19, 2008.

For your child’s safety, we require that all parents/guardians/babysitters sign their child out of camp each day. It is imperative that the staff is notified of any persons authorized to pick up your child from camp. A copy of the participant(s) birth certificate must be presented, even if your child has attended in the past.

Make checks payable to: South Fayette Township.

Please send completed registration form and appropriate fee along with a copy of the participant’s birth certificate to:
South Fayette Township • Summer Playground Program • 515 Millers Run Road • Morgan, PA 15064

No refunds after start of program.

PARENT/GUARDIAN AUTHORIZATION
I, the parent/guardian, will be responsible for any undue cost associated with the medical treatment or transportation of my child and will not hold South Fayette Township liable.
Parent/Guardian Signature: _________________________________________________ Date: ____________________

South Fayette Township will not be responsible for any toys, and held games or personal belongings your child may bring.

I agree to sign my child out of camp each day. If authorized persons are to pick up my child from camp, I will notify the staff.

I have read and understand the policies of the South Fayette Township Department of Parks and Recreation. My child and I agree to abide by all the rules and regulations in order to maintain the safety and security of this program.

Parent/Guardian Signature: ___________________________________Date: __________

Would you or a member of your family be interested in volunteering to assist with the Playground Program or any other Township Sponsored Event? (YES)

Child’s Name: ________________________ ________________________________
Last First


THE SUMMER PLAYGOUND PROGRAM WILL NOT OPERATE ON FRIDAY, JULY 4.

AM session start/end times 9:00-11:30 cost $5.00
PM session start/end times 12:30-3:00 cost $5.00
BOTH sessions start/end times 9:00-3:00 cost $10.00


ACTIVITIES SCHEDULE
Week 1 - June 23,25,27 - Morgan Park
AM 9:00-11:30 AM - PM 12:30-3:00 PM

Week 2 - June 30, July 2,4 - Middle School
Swimming
AM 9:00-11:30 AM - PM 12:30-3:00 PM
(No Program Friday, July 4)

Week 3 - July 7, 9, 11 - Fairview Park
AM 9:00-11:30 AM - PM 12:30-3:00 PM

Week 4 - July 14, 16, 18 - Morgan Park
AM 9:00-11:30 AM - PM 12:30-3:00 PM

Week 5 - July 21, 23, *24 - Middle School
Swimming
AM 9:00-11:30 AM - PM 12:30-3:00 PM
(Program will operate Mon, Wed & Thursday)

Week 6 - July 28, 30 Aug 1 - Fairview Park
AM 9:00-11:30 AM - PM 12:30-3:00 PM
Last day, Everyone’s Birthday

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