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Stevens Park Summer Recreation Program Parent/Guardian Acknowledgment

  1. Stevens Park Summer Recreation Program Parent/Guardian Acknowledgment

    The rate for the Summer Program is a flat fee of $110 per child and $90 for additional siblings if you live in the following zip codes, 20837, 20838, 20839, 20841, 20842. For children out of those zip codes the rate is $275. 


    Because safety is our primary concern, only authorized persons may sign the camper in and out each day. A completed and signed pickup authorization form MUST be on file for each child during registration. Changes may not be made on the original form. If changes are necessary, the original authorizer must complete a new form. Only individuals listed on the pickup authorization form will be allowed to pick-up the camper. PHOTO ID IS REQUIRED FOR ALL AUTHORIZED INDIVIDUALS. Campers cannot sign themselves out of camp.


    Campers can be dropped off no earlier than 9:15 a.m. A parent or guardian must sign the child in. Parents/guardians may not drop off a child (camper) unsupervised. The Town of Poolesville is not responsible for any children (campers) left on the recreation areas/playgrounds prior to official opening time. Pickup is at 3:30 p.m. Parents/guardians sign the child out.


    In the event of a late pickup, a parent/guardian should call camp staff as soon as possible. Staff are not permitted to transport children home under any circumstances. If a parent/guardian is more than 30 minutes late and has not contacted the camp supervisor, police may be called to assist the child. 


    • Campers must respect camp staff and follow camp rules

     • Treat other children, staff and visitors with respect

     • No weapons allowed on property 

    • No profanity, bullying or fighting (Seek camp staff for assistance)

     • No vandalism of property

     • Do not leave camp unless you are with camp staff or a parent/guardian 

    • Be kind to the environment and play areas


    Campers are expected to exhibit appropriate behavior while at camp. To provide campers and staff with a safe and enjoyable experience, the following guidelines have been developed. A caring and positive approach will be taken regarding discipline. Camp staff will reinforce appropriate behavior through positive reinforcement, clear statements, and redirection of activity. All campers must understand and follow the guidelines set forth.

    Listed below is the three-step disciplinary procedure for campers exhibiting unacceptable behavior. Depending on the severity of the behavior, a particular step may be skipped (i.e., aggressive behavior will not be tolerated).

     • Step 1: Verbal warning 

    • Step 2: Time out or time away from the group, based on age. During a time out, a camper may have to sit out from activities including games, crafts, or a special event. Parents/guardians will be notified of their child’s time out. Time outs for ages 5-6 will be 6 minutes; 10 minutes for ages 7-9; and 15 minutes ages 10-11. 

    • Step 3: Parent conference. If unacceptable behavior continues, the Camp Director or Assistant Camp Director will speak with the child and their parent/guardian. The parent/guardian will be required to sign a written warning and pick up the child from camp. After receiving two written warnings, the child will be expelled from camp. No refunds will be given. The staff will review these rules with campers on the first day of camp.

    The staff will review these rules with campers on the first day of camp.

    No routine medications are allowed at camp. Those medications must be taken at home.

    Camp staff do not administer shots or any therapy or treatment requiring physical contact or insertion into a body cavity. Any medical conditions, allergies or physical limitations must be listed on the camper’s health history form.

    Emergency medication such as an inhaler, EpiPen or diabetic injections are permitted. These must be clearly labeled with the camper’s name and directions for administering the drug. The Camp Director will collect medication and keep it in a safe, but easily accessible place for administrator use until camp departure. Medication will be stored according to the label’s storage instructions.

    Each parent is required to complete a Medical Administration Authorization form. Parents may obtain this form from the Camp Director. Any emergency medication brought to the Camp Program must be prescribed by a physician, be in its original container, and be clearly labeled with the following information:

    • Child’s first and last name
    • Legible dosage instructions for administering the medication

    • Date of prescription
    • Name of pharmacist and/or physician
    • Expiration date
    • Legible storage instructions


    • Lunch: Bring items that do not need refrigeration or heating. 

    • Water Bottle - Water is provided. 

    • Appropriate shoes and clothing: Camp is a time to have fun and not to worry about getting dirty during activities that are held each day. Campers must wear only closed-toed shoes or tennis shoes. No sandals or flip-flops. 

    • Items from home: Campers are not allowed to bring items/toys from home unless requested to do so by camp staff. Poolesville is not responsible for campers’ cell phone or other electronic devices. We strongly advise they be left at home.

    EMERGENCY ACTION PLAN-TRANSPORTATION During an emergency, a camper may need to be transported by a personal vehicle. By signing this agreement Parents/guardians consent to allow this form of transportation.

  3. I acknowledge that I, the parent/guardian of (campter(s) name) have received, reviewed and understand the expectations of the Town of Poolesville’s Stevens Park Summer Recreation Program.

  4. I have read and discussed the Disciplinary Policy with my camper.
  5. please type in the name of the parent/guardian

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  7. This field is not part of the form submission.