Summer Camp

2. Registration

   Registration forms for any and all weeks (with all fees paid) are due by June 1st - there are no exceptions.  This ensures adequate staffing and supplies. 

   Please select weeks your child will be attending: 

   1. July 3 - July 7 (no camp July 4)
   2. July 10 - July 14
   3. July 17 - July 21
   4. July 24 - July 28
3. Fee Schedule*

   1 Child - $75/week
   2 Children - $140/week
   3+ Children - $195/week

   After submitting this form,  you will be automatically redirected to our online payment portal.  Alternatively, the Township accepts checks payable to Easttown Township.

   *There may be financial assistance available for Easttown Township residents - please call the Township for more information (610-687-3000 x120).  All requests are kept confidential.

5. Child's Name
6. Date of Birth
7. Age (as of July 1st)
9. Entering Grade
10. School
12. Allergies or Special Considerations
14. Current Medications (including insulin)
15. Last Tetanus
17. Parent/Legal Guardian 1
18. Parent/Legal Guardian 2
20. Address
22. City
23. State
24. Zip Code
26. Phone Number
27. Email Address
29. People authorized to pick up your child

    Please note that proper identification is required and must be presented to the designated Camp Counselor at time of pickup or the child will not be released.

31. Name
32. Relationship
34. Name
35. Relationship
37. Name
38. Relationship
42. Family Doctor
43. Phone Number
45. Preferred Emergency Health Care Facility
47. Health Insurance Carrier

    All participants must be covered by health insurance.

49. Policy No.
50. Group No.
54. Emergency Information

    In case of an emergency, the following people shall be notified:

56. Emergency Contact 1
57. Relationship
59. Phone Number
60. Email Address
62. Emergency Contact 2
63. Relationship
65. Phone Number
66. Email Address
70. Consent for Emergency Health Treatment

    Pennsylvania Law requires consent be given before medical, dental or health care services may be rendered to a minor, except-where in the judgment of the physician-an attempt to secure such consent would result in the delay of treatment, which would create a risk to the minor's life or health.  Even when consent has been provided, all reasonable efforts will be made to contact you or any persons listed as emergency contacts in connection with any emergency treatment.

    Consent of the undersigned parent/legal guardian is hereby given to administer emergency medical, dental and health services to the minor child listed in this form.

72. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
74. Parent/Legal Guardian Electronic Signature
75. Date
    Date
79. Acknowledgement

    I, the undersigned Parent/Legal Guardian, understand that my child is expected to stay each day, Monday through Friday, 9:00 AM-12:00 PM, on the weeks they are registered.  I will take responsibility for his/her arrival and departure each day, and understand that failure to do so will result in my child not participating in the program, as determined by the Camp Director.  I understand that there is no assurance of my child's placement with a friend or particular group of children.  I agree that the Township and its recreational staff shall have the right to enforce rules and terminate participation by anyone failing to comply with the rules.

    I also acknowledge that the Easttown Township Summer Recreation Program involves active physical recreation and inherent risks, which could result in injury to the participant or damage to personal property.  The undersigned hereby assumes all risks and responsibility of possible damage or injury through participation in recreational activity and understands that insurance should be in place and furnished in case of injury.  I agree to indemnify and hold harmless the Township, its officers, employees, and summer recreational staff for personal injury or property damage resulting from participation in the normal course of recreational activity.  

81. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
83. Parent/Legal Guardian Electronic Signature
84. Date
    Date
Leave This Blank:


86. 1. Receive an email copy of this form.
87. Email address

    This field is not part of the form submission.

88. Submit

* indicates a required field