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PLEASE NOTE: IF YOUR CHILD IS NOT ENTERING 1ST OR 5TH GRADE THEY WILL NOT BE GUARANTEED A SPOT IN SUMMER CAMP. PREFERENCE WILL BE GIVEN TO THE 1ST-5TH GRADERS.
Please initial each item
In consideration of accepting my child’s entry into the Burlington Parks and Recreation Department’s
Burlington Summer Day Camp, I hereby, for myself, my child, my heirs, executors and administrators, waive and
release any and all rights and claims for damages I, or my child may have against the Burlington Parks and
Recreation Department, City Council, and its successors and assigns, its employees, agents, officers, and directors
for any and all injuries suffered by myself or my child at an activity sponsored by these groups.
The Burlington Parks and Recreation Department will immediately involve the authorities if any child
should run away from the program. I further understand the risks inherent to the activity for which my child is
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.
I understand that the rules of Burlington Summer Day Camp are designed for the well being and safety of
the children participating, and failure to comply with these rules may result in suspension from program activities.
These rules and regulations are for the safety and well-being of all campers. Attendance at Burlington Summer
Day Camp is considered a privilege. We ask for parental support when you are informed of a behavior
First offense, the child will be pulled aside from the activity, given a warning and the staff person will talk to
the child about the behavior expected of him/her.
Second offense, the child will be asked to sit away from the group for a short period of time (5-15 minutes) to
think about his/her actions. A staff member will talk to the child again about his/her behavior.
Third offense, the child will be removed from the area and asked to sit away from the group for 20-30 minutes.
The child will be given a book or paper and pencil to assist in occupying the time. The child will not be allowed
to return to the special activity of the day. Parents will be informed of the behavior upon pickup by a highlighted
notation next to the child’s name and the staff will create a Behavior Report.
A Discipline Report will be completed whenever a child becomes physical with another child or staff member,
destruction of property occurs, behavior is adversely affecting the operation of the program, and/or usage of
offensive language. A Discipline Report will be completed by the Recreation Manager, or in his/her absence,
the Site Manager. If 2 Discipline Reports are accrued, a meeting will be scheduled with the Recreation
Manager, parents, and child to discuss the behavior and strategies to assist in alleviating the behavior.
If the child receives a 3rd Discipline Report during the course of the summer, he/she will be suspended from
the program for a period of 3 summer camp days. During this time, the parents, child, and Recreation Manager
will meet again to discuss the parameters for returning to the program.
A Fourth offense will result in dismissal from the program.
The above steps are followed for the majority of discipline problems but if an offense is deemed serious
enough by the Recreation Manager, a child can be expelled upon first offense. An example would be if a child
brought a weapon from home.
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.
I agree that my child may view any PG movies while in attendance at camp.
(If no, please leave blank)
I understand that my child will be offered an alternate activity when a movie is viewed at the park.
I understand that if a movie is shown at the movie theatre and I wish for my child to not attend, my
child may have to be withheld from attending the program for the duration of the event or until the activity is
complete. I understand that Burlington Parks and Recreation and The City of Burlington Summer Day Camp
cannot provide adequate supervision to children who are not able to partake in the field trips at the movie
I give consent for the participant to be photographed, videotaped or filmed while participating in the
summer camp program and for the resulting record to be used by the City of Burlington for educational and
promotional purposes. __ I give consent for the participant to be photographed by local news media while participating in the
summer camp program. The resulting record will be used for educational and promotional purposes.
I understand that an early fee of $1 per every 1 minute early will be assessed before my child’s
scheduled drop off time and a late fee of $1 per every one minute late will be assessed after my child’s
scheduled departure time. Early and late fees must be paid within one week of the date issued.
My child’s immunization records are current as required by the State of Iowa Public Health for my
child to attend school.
I understand that all items bought to camp are the responsibility of my child. Although Burlington
Summer Day Camp kindly requests that all electronics and toys are left at home, please be aware that if
electronics or toys come to the program, their safekeeping is the complete responsibility of each participant.
Burlington Parks and Recreation and The City of Burlington Summer Day Camp are not responsible for lost or
I understand and agree that:
The Burlington Parks and Recreation Department and The City of Burlington Summer Day Camp will provide
reasonable supervision of the participants within its care and control. The supervision will be appropriate for
the age of the participants, but Burlington Parks and Recreation and The City of Burlington Summer Day Camp
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. I hereby grant permission for my child to travel on field trips sponsored by the Burlington Parks and Recreation
Department and The City of Burlington Summer Day Camp.
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
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