2. STEVENS PARK SUMMER RECREATION PROGRAM
   2023 REGISTRATION FORM

   
   June 26th – August 4th 9:30 am – 3:30 pm
   For Elementary School Age Children (entering Kindergarten to 5th Grade)
   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. You can pay the fee in person at Town Hall via check or credit card, by mail or on the first day of camp.   

    For the PDF version of this form Click Here.

4. Child's Name
5. Birth Date
6. Age
8. Parent or Guardian Name
10. Address1
12. City
13. State
14. Zip
16. Email Address
17. Phone Number
19. Allergies
    Please specify the allergies that your child has.
21. In case of emergency, notify:
23. Name
24. Name
26. Address
27. Address
29. Phone
30. Phone
32. Release of Liability / Photo Release

    1. I agree

    By clicking agree, I the parent or legal guardian of the above named child, I certify that said child has my permission to attend and participate in the Poolesville Summer Recreation Program. In signing this form, I hereby waive and release all other participants, the host, sponsors, and all other officials or parties involved in the recreation program. I also hereby grant the authorities the unconditional right to use the name, voice, and photographic likeness of the above named child in connection with any of their articles or press releases, but not as endorsement.
    
    I understand that said child is enrolled for instruction and experience in sports, games, and crafts and is expected to be a participant in the planned activities. It is further understood that any child who excuses him or herself from the activities is expected to “sit - out” completely for the duration of the session. Parents are responsible for any damage done by the youngsters absenting themselves from the activities.
34. Parent/Legal Guardian Signature:
35. Date:
    Date:
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field