Independence Lake Park – 2016 Summer Camp Registration Form

Independence Lake Park – 2016 Summer Camp Registration Form ● 734-484-9676 ● https://parksonline.ewashtenaw.org
For children who have completed Kindergarten through 11 years of age.
One form per child
Child’s Name: ____________________________________ Birthdate: _________ Age: ____
Gender: M or F
Parent or Guardian Name: ____________________________________________ Primary Phone # :_____________________________________
Address: _______________________________City:____________ Zip: _________ Email Address :_______________________________________
In order to provide the most positive experience for your child, please provide any information in regards to your child’s behaviors, tendencies, needs
and unique qualities:______________________________________________________________________________________________________
Please check the space next to the week(s) for which you are registering.
Week #
1
2
3
4
5
6
7
8
9
10
Dates
June 20-24
June 27-July 1
July 5-8
July 11-15
July 18-22
July 25-29
August 1-5
August 8-12
August 15-19
August 22-26
Fee
150.00
150.00
120.00
150.00
150.00
150.00
150.00
150.00
150.00
150.00
Pre-camp
15.00
15.00
15.00
15.00
15.00
15.00
15.00
15.00
15.00
15.00
Post-camp TOTAL
15.00
15.00
15.00
15.00
15.00
15.00
15.00
15.00
15.00
15.00
TOTAL
Select Payment Option (Cash accepted in person):
Check/Money Order. Make checks payable to WCPARC.
One time credit card payment (pay in full)
PAYMENT PLAN (Cannot be done online. Form must be submitted.)
$25 deposit per child/week due at time of registration. Balance for Weeks 1-3
charged June 1; Weeks 4-7 charged July 1; Weeks 8-10 charged August 1.
Card Number ____________________________________ Exp date_____/______
Signature___________________________________________________________
Washtenaw County Parks & Recreation Commission
Summer Day Camp - Policies
Cancellations
All cancellation requests must be submitted in writing to the Camp
Director no later than 5pm on the Thursday prior to the enrolled
session. Cancellations submitted by the deadline will be refunded,
minus a $25 cancellation fee per week, per child. No refunds will be
issued for requests submitted after the deadline without a physician’s
note for illness or injury.
Transfers
All transfer requests must be submitted in writing to the Camp Director
and will only be processed if space allows. After June 1, all transfers
will incur a $10 fee per week, per child. Registration transfers
between locations (Independence Lake County Park, Meri Lou Murray
Recreation Center, and Rolling Hills County Park) will also incur a $10
fee per week, per child. Transfers are not permitted after the enrolled
session has begun.
Zero Tolerance
WCPARC Camps have a zero tolerance policy towards physical
violence of any nature. Incidents involving any type of violent act will
result in a meeting with camp administration, and disciplinary
suspension, possibly including an expulsion from camp. I understand
that my child will be expected to comply with the established guidelines
for camp, which require children to refrain from using any foul
language, hitting, biting, and or using threats, etc.
Waiver
I attest that my child is physically capable of participating and give my
permission to participate in all activities in the above program for which
I have registered and hereby release Washtenaw County Parks and
Recreation Commission from any responsibility whatsoever for
personal injuries, damages, or loss of equipment resulting from
participation.
OFFICE USE ONLY:
Signature
Check #
Cash Amt $
CC Approved
Staff Initials
Date
Date
Independence Lake Park, 3200 Jennings Rd., Whitmore Lake, MI 48197
FAX: 734-449-8507
WCPARC Tax I.D. #38-6004894