2016 Authorization to Release/Transportation Form Barton Day

Authorization to Release/Transportation Form
Barton Day Camp Summer 2016
(This form must be filled out for every camper even if not requesting transportation.)
Camper’s Name: ______________________________________________________________
Parent’s/Guardian’s Name: ______________________________________________________
Home Phone: _______________ Work Phone: _______________ Cell Phone: _______________
Parent’s/Guardian’s Name: ______________________________________________________
Home Phone: _______________ Work Phone: _______________ Cell Phone: _______________
My child is attending:
◊The Rainbow Club - Greenwich, CT
◊ I will be on camp for the parent program the whole week.
◊ I will be on camp the following parent program days: __________________________
◊ I will not be on camp.
◊ Long Island Day Camp—Week 1 – Old Westbury, NY
◊ I will be on camp for the parent program the whole week.
◊ I will be on camp the following parent program days:___________________________
◊ I will not be on camp.
◊ Long Island Day Camp—Week 2 – Old Westbury, NY
◊ I will be on camp for the parent program the whole week.
◊ I will be on camp the following parent program days:___________________________
◊ I will not be on camp.
◊ Worcester Day Camp – North Oxford, MA
◊ Danvers Day Camp – Danvers, MA
Transportation: Available for Worcester and Long Island Camps. Transportation
will be from centralized pick up and drop off locations.
◊ I will provide transportation for my child to and from Barton Day Camp.
◊ I will need transportation to and from Barton Day Camp for my child. (Please fill out back of this
form.)
◊ I have enclosed my fee of $125.00
Please list the names and relationship of three people other than yourself who may pick your child
up from camp if you are unable to. In addition, please let us know if your child is familiar with the
person listed. A picture ID is required for camper’s release to all.
Name:
Relationship:
Contact Number:
Known by child:
______________________________________________________
Yes/No
______________________________________________________
Yes/No
______________________________________________________
Yes/No
2016
Please list ANY person who may try to pick up your child from Barton Day Camp without your
authorization. Should an unauthorized person attempt to pick up your child, a telephone call will be
made from the Barton Day Camp Staff immediately to the parent/guardian. The child will not be
released from staff without parent/guardian written permission.
_________________________________________________________________________.
Parent/Guardian Signature:__________________________ Date:______________________
Transportation Options
Worcester: (Please circle your choice)
25 Research Drive Westborough, MA Comfort Inn (Solomon Pond Mall) Barbers Crossing Sterling, exit 6 off Route 190 Vernon Medical Center Long Island Day Camp: (Please circle your choice) Key Foods, 399 Ocean Avenue, Rockville Centre Sunrise Mall, Massapequa, Wal‐Mart King Kullen, 275 W Jericho Turnpike, Huntington Station Plainview Bowling Alley An email will be sent to you at the address you indicate below as a confirmation of your transportation choice. Included in this email will be a contact number for the staff member traveling with your camper and times for am and pm pick up and drop off. Email address to send confirmation to:_____________________________________________________ 2016