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I as parent, guardian or applicant over 18, agree that the City of Burlington and all individuals participating in the activity in any capacity, will not be liable for any losses, claims, or injuries of any kind arising from out of the participation of the applicant in the activity and hereby release all said individuals from such liabilities. The undersigned acknowledges that in all activities there are certain risks of physical injuries and that the applicant will participate at applicant’s own risk. In the event that the activity requires transportation, the city will not be held liable and release all individuals from liabilities.
I give consent for the applicant to be photographed, videotaped or filmed while participating in the activity and for the resulting record to be used by the City of Burlington for educational and promotional purposes.
In the event that my child may require medical and/or surgical care wile I am out of the city or otherwise unreachable I hereby authorize the staff to seek emergency medical care.
I have read and understand the above and am signing this document of my own free will.
It is the policy of the Burlington Parks and Recreation Department to use the following procedures concerning disciplinary problems:
1. The child will be given verbal warnings. The nature and date of each warning will be recorded. Time out or not participating in an activity will be used to encourage proper behavior.
2. A third warning given to a child will result in a meeting between the child and the Recreation Manager. A written warning will be issued and the parents notified.
3. The fourth warning will constitute a dismissal from camp for 1 day.
4. The fifth warning will constitute a dismissal from camp for 1 week.
5. Any further warning will lead to termination from the program without a refund.
Dismissal from camp may occur without going through the above mentioned steps if the situation is warranted.
I (parent/guardian), have read the Burlington Parks and Recreation Disciplinary Policy and fully understand the disciplinary procedure. I will abide by the above policy.
The following people are authorized to pick up your child from camp. The following list will also be used in the event of an emergency or illness. Please put the authorized pick up list in the order you wish people to be contacted.
As part of our youth program, we sometimes attend field trips at the Mall Theatre or show movies on rainy or hot days. G rated movies are shown to the children. Many PG rated movies may be enjoyable and appropriate, and we require parental approval before PG movies can be shown. Please list any PG movies that your child may not view. If you choose that your child may not view any PG movies, please return this form without signature and your child will be offered an alternative activity at camp. No PG13 movies will be shown.
To ensure your child has the best camp experience, please try to make an accurate projection of when your child will be attending camp. Staffing, materials, and activities have to be planned well in advance. Registration deadline is May 2, 2016!
I agree to pay a $140 deposit to hold my child’s spot in camp. This fee includes a $75 fee used for activities as well as covering the cost for my child’s first week of camp. All subsequent payments of $65 will be made the Monday of the week my child attends. THIS FEE IS NON-REFUNDABLE!!!!
Field Trips can include, but are not limited to, Starr’s Cave, Dankwardt Pool, Kenny’s Roller Rink, Putt-Putt Golf, and Steamboat Days. Parents will be notified of the week’s field trips in a letter sent home when services are paid.
I, the parent/guardian of the above named child hereby grant permission for my child (or ward) to travel on Field Trips sponsored by the Burlington Parks and Recreation Department.
I understand and agree that: the Burlington Parks and Recreation Department will provide reasonable supervision of the participants within its care and control. The supervision will be appropriate for the ages of the participants, but Burlington Parks and Recreation is not an insurer of the safety of any participants, nor can it supervise all movements of all participants at all times. There are certain risks inherent in travel and at the destination.
I agree that no employee or volunteer has any personal liability unless he or she has acted recklessly, wantonly, or intentionally to injure my child
Please make checks payable to City of Burlington and mail to:
ATTN Tabetha Gerdner
400 Washington St
Burlington, IA 52601
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