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2013 SUMMER FUN REGISTRATION FORMS

2013 SUMMER FUN REGISTRATION
Tel. # (508) 886-0048
Child’s Name: _____________________________________________________ ~Age: ____________
Grade Entering: ___________  Age: ___________  T-shirt size: _______ youth or _______ adult
Address: ____________________________________________________________________________
Parent Name(s): ____________________________________________________________________
Home Phone: ________________________________ Cell/Work: ____________________________
Email Address: ~_____________________________________________________________________
Medical Conditions/Medications:______________________________________________________
Emergency Contact and Phone #: _____________________________________________________

Session Time
Fee
#1: 9am-12pm – ½ day program
$80
#2: 8am-12pm – ½ day program with early drop-off
$85
#3: 8am-5pm full day program
$185
#4: 9-12 dance program (week of July 8th and week of July 15th)
$80
#5: Pre-engineering with Legos, ages 5-7 (week of August 12th, 9am-12pm)
$150
#6: Engineering Fundamentals with Legos, ages 8-11 (week of August 12th, 1-4pm)
$150
The cancellation/refund policy will be strictly enforced.

session
dates
theme
time
fee
1
July 8-12
“Color Wars”
2
July 15-19
“Sports & Games”
3
July 22-26
“Party in the USA”
4
July 29-August 2
“Wacky Water Week”
5
August 5-9
“Amazing Race”
6
August 12-16
Legos
I agree not to hold responsible the Rutland Recreation Committee; the Town of Rutland; or any of the parties connected with this program for any accident or injury that may occur during the program. I understand that if my child becomes a discipline problem, he/she will be dismissed from the program without a refund. I also grant permission for the Recreation Staff to seek medical care for my child in the event that I cannot be reached.
(Parent/Guardian):___________________________________________________Date:______________________________
I give permission for pictures taken of my child in this program to be displayed:________(initial)
Check #: ______________ Date:______________ Amount:______________

“This Institution is an equal opportunity provider.  To file a complaint of discrimination
write USDA, Director, Office of Civil Rights, Washington, DC 20250-9410



 
Town of Rutland 250 Main Street, Rutland, MA 01543   Disclaimer
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