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Watertown Recreation Department

149 Main Street ● Watertown, MA 02472
Phone: 617-972-6494 ● Fax: 617-926-6129 ●

This form includes permission authorization for Bus Transportation, Pequossette Swimming Program and a Media Waiver.
For each section, you must check or circle one or more options. Complete your child’s information and sign at the bottom
of this document. Your child will not be allowed to participate in the program unless this form is returned.

Child’s Name: _________________________________________ Age ______ Child’s Grade in Fall ’17: _____________
Address: _____________________________________________________ Telephone: _________________________


The Watertown Recreation Department throughout the course of the Pequossette Summer Day Program will transport
children by a school bus to various locations in and out of Watertown. The local bus trips include the DCR pool, all
Watertown Parks and the Watertown Boys and Girls Club. All are well monitored by our staff for the children’s safety.
Trips will also be taken to locations outside for Watertown on special occasions.

Please check one:
_____ I allow my child to ride on the bus _____ I don’t allow my child to ride the bus

General Description of Swimming Program:
- Pequossette swims at the Dealtry Pool on Pleasant Street and the Boys & Girls Club on Whites Avenue.
- Campers will swim at least three times a week at either pool – days will vary.
- Both pools are staffed by lifeguards and are constantly supervised by Pequossette staff.
- Please contact the Pequossette Administrative Staff with any questions or concerns.
- You must identify swimming options for both pools:

Dealtry Pool – Please check one

_____ Sprinkler _____ Shallow End (3.9 ft.) _____ Entire Pool (up to 6 ft.)

Boys & Girls Club Pool – Please check one

_____ No Pool _____ Shallow End (3.5 ft.) _____ Entire Pool (up to 10 ft.)


I hereby assign all rights and release the Watertown Recreation from liability from recording, reproduction, exhibition,
telecasting and distribution of my child’s visual image and voice for non-profit use, print media and the town website. I
certify that I am the parent or legal guardian of _______________________________, a minor under the age of 18 years.

Please circle one:
I hereby consent OR I hereby do not consent that any videotapes, print media and town webpages which have
been or are about to be made by the above Watertown Recreation may be used for the purposes explained above.

Parent’s Name: __________________________ Parent’s Signature: _________________________ Date:____________