999 Lower Ferry Road -- Ewing, New Jersey 08628 -- Phone: 883-1776 -- Fax: 883-5023

The Teen Travel Camp is a seven week travel program designed exclusively for “teens” entering 7th, 8th, 9th, & 10th grades in the fall of 2010. Registration fee includes: transportation for trips, admissions to activities, and a T-shirt for each registrant. Each day the group will meet at the Ewing Senior/Community Center at 999 Lower Ferry Road. Camp hours will be from 8:30 a.m. to 4:30 p.m. with extended hours for longer trips. *Changes in trips may be required due to the weather, availability, etc. *For more information on schedules or if you have questions, call the Recreation Office or Diane Fisher, director, at 609-915-6186. *Campers entering 10th grade have the option of enrolling in the Teen Travel program and/or the CIT program through the Ewing Recreation Day Camp. They have the choice of splitting the weeks up between the two programs if preferred. Separate registration form for the Day Camp is required to be completed if splitting the weeks.

CAMPER ENROLLMENT APPLICATION
CAMPER INFORMATION
Last Name: ________________________________ First Name: __________________________ Birthdate: ____ /____ /______ Age: _______ Gender:

Male

Female

Grade in September 2010: _________ School Attending in Sept. 2010 : _________________________ Home Address: _____________________________________________ City: _______________________________ __ State: __________ Apt # ________

Zip: ___________

Home phone: (____)__________________ Camper’s Email: ____________________________ Shirt Size Please Circle: (Adult) S M L XL

PARENT or GUARDIAN INFORMATION (Please include home address if different than camper.)
Father’s Name: _________________________ Address: ______________________________ City/State/Zip: __________________________ Home Phone: ___________________________ Work Phone: ___________________________ Cell Phone: ____________________________ Email: _______________________________ Mother’s Name: __________________________ Address:________________________________ City/State/Zip: ___________________________ Home Phone: ____________________________ Work Phone: ____________________________ Cell Phone: _____________________________ Email: _________________________________

If parents live at different addresses, do you want camp information to be sent to both? ____Yes ____No

EMERGENCY INFORMATION
Physician’s Name: _____________________________ Phone Number: _____________________

In the event the parent(s) or guardian can not be reached please contact: Name : ___________________________________ Relationship: ______________________
(continued on next page)----

Home Phone Number: ________________________ Work/Cell Number: _____________________

Will teen need to take medication during the camp day? _____ (If yes, attached medication form MUST be
completed)

PICK UP AUTHORIZATION The following person(s) are authorized, in addition to the mother and father or guardians listed above, to pick up my teen from the Ewing Recreation Teen Travel Camp. __________________________________________________________________________________________ Name Phone # Relationship to Teen __________________________________________________________________________________________ Name Phone # Relationship to Teen __________________________________________________________________________________________ Name Phone # Relationship to Teen

TEEN TRAVEL CAMP WEEKS & COSTS – Week 1: $200 for residents; $300 non-residents.
All other weeks (except week 6) $250 per week for residents; $375 per week for non-residents. Week 6-overnight trip: $275 for residents; $400 for non- residents. (Please check the specific weeks attending and residence status) ____ Resident ____ Non-Resident

____ ____ ____ ____

Week 1: July 6 – July 9 Week 3: July 19 – July 23 Week 5: August 2 – August 6 Week 7: August 16 – August 20

____ ____ ____

Week 2: July 12 – July 16 Week 4: July 26 – July 30 Week 6: August 9 – August 13 **

** In order to register for week 6, camper must
also register for and attend at least one other full week prior to week 6.

COMMENTS/REQUESTS/SPECIAL NEEDS (Documentation may be required before the start of camp)
________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

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Make Checks payable to “EWING RECREATION DEPARTMENT” ($50 per week deposit must accompany registration form) Amount Enclosed____________________ Name on Card: _________________________ Exp. Date _____________ Check # _________________ Credit Card # _____________________________ VISA MasterCard Amex

Credit Card Type:

PARENT’S SIGNATURE: _______________________________________ DATE: _____________
--------OFFICE USE ONLY ---------------------------------------------------------------------------------------- Receipt # ____________ Amount paid: ___________ Partial pmt. _____ or Full Pmt. _______ Received by: __________________

ACKNOWLEDGEMENT OF RISK
Program: Ewing Recreation Teen Travel Camp I am aware that participating in this activity can be dangerous and involves risk of injury. I realize that participation in the above-mentioned activity presents risk, which includes minor or serious injury to any part of the body. These injuries could lead to temporary or permanent disability or even death. While the possibility of serious injury to participants is unlikely, it is important that all participants and parents realize that these risks do exist. PARENT/GUARDIAN AGREEMENT I also recognize and acknowledge that there are certain risks of physical injury inherent in the named minor’s participation in this program. I have received, read, and understand the risks and have discussed them with my teen. He/she understands that he/she must obey all rules and regulations, follow all safety procedures, and obey any and all instructors, assistant instructors, and staff members assigned to the program. My teen and I understand the risk associated with this program, my teen and I agree to accept our responsibility in making this program a safe one. I certify that the minor is in proper physical condition for safe participation in the Ewing Recreation Teen Travel Summer Camp, and I agree that it is incumbent upon me to immediately inform the Ewing Recreation Teen Travel Director should the minor’s physical condition change at any time prior to or during his/her participation in the program. I expressly agree that this agreement is intended to be as broad and inclusive as permitted by the Laws of the State of New Jersey and that if any portion of the agreement is held invalid, it is agreed that the balance shall continue in full legal force and effect and be valid. In consideration of the Ewing Recreation Department permitting the name minor to participate in the Recreation Department previously mentioned, the undersigned, being the parent(s) or legal guardian of ____________________________________________________ hereby waive and relinquish all claims I (we) may have as a result of said minor participating in the program against the Ewing Township Recreation Commission, Ewing Township Recreation Department and Ewing Township Mayor and Council, its offices, agents, servants and employees from any and all claims for injuries including death, damage or loss of property which may accrue to us on account of the minor’s participation in said program, and we further agree to hold harmless the Ewing Township Recreation Commission, Ewing Recreation Department and Ewing Township Mayor and Council, its officers, agents, servants, and employees from any and all such claims. Terms and Conditions
Refunds will only be given 10 days prior to the week in which your child is registered to attend. No refunds or substitute days due to absence, late arrival, early departure or dismissal for cause or camp closing. If the camper is absent for medical reasons of more than 7 consecutive days, a refund will be made for each day missed after the 7 day deductable period. A physician’s note must be provided. Camp is not responsible for clothing or personal belongings lost on premises or on trips. Parent hereby grants permission for the Ewing Recreation Teen Travel Camp to photograph & video his/her teen and to use these pictures for website, brochures, and display purposes. The Teen Travel Camp reserves the right to evaluate any child with physical, mental, or emotional disabilities prior to camp. For the general welfare of campers, the Camp reserves the right to dismiss any camper whose conduct or influence is inimical to the Camp’s best interest. I hereby give permission to the Ewing Recreation Teen Travel Camp to take my teen on trips outside of the camp. The Director and staff will exercise every reasonable precaution consistent with safety, health, and care. Furthermore, in the event that I or my family physician can not be contacted in the event of an emergency, I hereby grant permission to the nearest medical facility to provide a physician and to give emergency treatment to my child.

Parent or Legal Guardian [indicate which] ___________________________________________
SIGNATURE

_______________________
Date

___________________________________________
PRINT NAME

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