EB2Gov POS

KENSINGTON
Summer Camp 2024
Stephanie Kosakowski
kensingtonreccamp@gmail.com

Kensington Summer Camp

Registration and Payment

(***SOME WEEKS ARE FULL - SEE BELOW***)

6/17-6/21 Week 1: Sports

6/24-6/28 Week 2: Hollywood

7/8-7/12 Week 3: Mad Scientist

7/15-7/19 Week 4: Shark Week (****FULL****)

7/22-7/26 Week 5: Sports 2.0

7/29-8/2 Week 6: Nature

8/5-8/9 Week 7: H2O

8/12-8/16 Week 8: Carnival

Kensington Residents Before April 1st- Regular Day: $185 Extended Day: $235

Non- Kensington Residents Before April 1st- Regular Day: $210 Extended Day: $260

Kensington Residents After April 1st Regular Day: $205 Extended Day: $255

Non- Kensington Residents After April 1st- Regular Day: $230 Extended Day: $280

Hours of Camp:

Monday - Friday: 8:15 AM - 3:15 PM*

Dropoff: 8:15 to 8:30 AM

Pick-up: 3:15 to 3:30 PM

*Aftercare at Sawyer Park (+$50/week)

3:15-3:30 Snack

3:30-4:00 Group game

4:00-4:30 Board/card games

*Aftercare will be offered based on enrollment. Aftercare is a down time after camp.

Form Information:

Selection of Weeks: Select each week that you wish to have each camper attend. If you wish to also do Extended Day, choose those weeks as well.

Pay in Person or Financial Assistance: If you wish to pay in person, you are in need of financial assistance or you are a #AREUIN? card member. Select "9 - Pay In Person (Select Weeks Below)", then select your weeks in the Pay in Person checkboxes. Those doing Pay in Person, please pay the Town of Kensington Town Clerk with a check (you'll need to add up the total $ amount owed). If you are in need of financial assistance, or are already a #AREUIN? card member, please email kensington@kensingtontown.com once your registration is complete.

---- Pay in Person still requires this registration page to be completed and there will be a small charge ($1.75) required to complete the registration. Thank you for your understanding. ----

Shirts: Shirts are an additinal $8 and are optional. Do not choose a shirt size if you do not want to buy one.

Alternate Pick-ups: Please list three alternate contacts for your family in the order which contacts should be called first in the case of an emergency. These contacts will also be authorized pick-ups for your child unless otherwise specified.

Medications and Allergies: List any specific medications, allergies or other conditions that the Director should be aware of.

Allergens, Symptoms and Medication Procedures: Fill out these sections with additional information if your camper has any allergies that the Director should be aware of.

Medical Procedures: Please indicate all steps necessary and the order in which they should be taken. Also indicate if the steps should be administered immediately upon exposiure to allergen.

Kensington Summer Camp

Registration and Payment

(***SOME WEEKS ARE FULL - SEE BELOW***)

6/17-6/21 Week 1: Sports

6/24-6/28 Week 2: Hollywood

7/8-7/12 Week 3: Mad Scientist

7/15-7/19 Week 4: Shark Week (****FULL****)

7/22-7/26 Week 5: Sports 2.0

7/29-8/2 Week 6: Nature

8/5-8/9 Week 7: H2O

8/12-8/16 Week 8: Carnival

Kensington Residents Before April 1st- Regular Day: $185 Extended Day: $235

Non- Kensington Residents Before April 1st- Regular Day: $210 Extended Day: $260

Kensington Residents After April 1st Regular Day: $205 Extended Day: $255

Non- Kensington Residents After April 1st- Regular Day: $230 Extended Day: $280

Hours of Camp:

Monday - Friday: 8:15 AM - 3:15 PM*

Dropoff: 8:15 to 8:30 AM

Pick-up: 3:15 to 3:30 PM

*Aftercare at Sawyer Park (+$50/week)

3:15-3:30 Snack

3:30-4:00 Group game

4:00-4:30 Board/card games

*Aftercare will be offered based on enrollment. Aftercare is a down time after camp.

Form Information:

Selection of Weeks: Select each week that you wish to have each camper attend. If you wish to also do Extended Day, choose those weeks as well.

---- Pay in Person still requires this registration page to be completed and there will be a small charge ($1.75) required to complete the registration. Thank you for your understanding. ----

Shirts: Shirts are an additinal $8 and are optional. Do not choose a shirt size if you do not want to buy one.

Medications and Allergies: List any specific medications, allergies or other conditions that the Director should be aware of.

Allergens, Symptoms and Medication Procedures: Fill out these sections with additional information if your camper has any allergies that the Director should be aware of.

Medical Procedures: Please indicate all steps necessary and the order in which they should be taken. Also indicate if the steps should be administered immediately upon exposiure to allergen.

Summer Camp Registration

Parent Name:

Primary Phone Number:

Secondary Phone Number:

Email:

Are you a resident of Kensington?:

Street Address:

Town:

Zip Code:

Name:

Phone Number:

Relationship:

Name:

Phone:

Town:

Relationship to Camper:

Name:

Phone:

Town:

Relationship to Camper:

Name:

Phone:

Town:

Relationship to Camper:

Campers Name:

Date of Birth:

Entering Grade:

Shirt Size:

Resident: Regular Day Camp (pick up at 3:15pm):

Non-Resident: Regular Day Camp (pick up at 3:15pm):

Extended Day Camp (+$50/wk pick up at 4:30pm):

Permission to use photos (See Agreement at bottom):

Regular Day (Pay In Person - Res / Non-Res):

Extended Day ($50 Pay in Person):

Physician Name:

Physician Phone:

Medical Insurance Company:

Policy #:

List any allergies or other medical conditions:

List any medications:

List any activity restrictions:

Bee Sting

Other Insect Bites (List if Applicable):

Animal Fur (List if Applicable):

Food Allergy (List if Applicable):

Other (List if Applicable):

Shortness of breath or difficulty breathing

Swelling of the face or lips

Hives

Vomiting

Diarrhea

Other (Explain):

1 - Give Benadryl Elixir, ml orally

2 - Administer EpiPen Jr or (below)

EpiPen alternative:

3 - Call emergency medical personnel (eg 911)

4 - Camper may administer own medication

5 - Other:

List order of procedure (eg 4,5,3):

Campers Name:

Date of Birth:

Entering Grade:

Shirt Size:

Resident: Regular Day Camp (pick up at 3:15pm):

Non-Resident: Regular Day Camp (pick up at 3:15pm):

Extended Day Camp (+$50/wk pick up at 4:30pm):

Permission to use photos (See Agreement at bottom):

Regular Day (Pay In Person - Res / Non-Res):

Extended Day ($50 Pay in Person):

Physician Name:

Physician Phone:

Medical Insurance Company:

Policy #:

List any allergies or other medical conditions:

List any medications:

List any activity restrictions:

Bee Sting

Other Insect Bites (List if Applicable):

Animal Fur (List if Applicable):

Food Allergy (List if Applicable):

Other (List if Applicable):

Shortness of breath or difficulty breathing

Swelling of face or lips

Hives

Vomiting

Diarrhea

Other (Explain):

1 - Give Benadryl Elixir, ml orally

2 - Administer EpiPen Jr or (below)

EpiPen alternative:

3 - Call emergency medical personnel (eg 911)

4 - Camper may administer own medication

5 - Other::

List order of procedure (eg 4,5,3)::

Campers Name:

Date of Birth:

Entering Grade:

Shirt Size:

Resident: Regular Day Camp (pick up at 3:15pm):

Non-Resident: Regular Day Camp (pick up at 3:15pm):

Extended Day Camp (+$50/wk pick up at 4:30pm):

Permission to use photos (See Agreement at bottom):

Regular Day (Pay In Person - Res / Non-Res):

Extended Day ($50 Pay in Person):

Physician Name:

Physician Phone:

Medical Insurance Company:

Policy #:

List any allergies or other medical conditions:

List any medications:

List any activity restrictions:

Bee Sting

Other Insect Bites (List if Applicable):

Animal Fur (List if Applicable):

Food Allergy (List if Applicable):

Other (List if Applicable):

Shortness of breath or difficulty breathing

Swelling of the face or lips

Hives

Vomiting

Diarrhea

Other (Explain):

1 - Give Benadryl Elixir, ml orally

2 - Administer EpiPen Jr or (below)

EpiPen alternative:

3 - Call emergency medical personnel (eg 911)

4 - Camper may administer own medication

5 - Other:

List order of procedure (eg 4,5,3):

Full Name - Agrees to Waivers and Agreements below:

Amount:

EB2Gov Fee:

Quantity:

Payment Amount:

Notes:

Upload Files:

image size limit is 4 MB, 5 images max

---- Please upload recent phyisical and immunization records using "Upload Files" in the Transaction Details section ----

WAIVERS and AGREEMENTS (READ FULLY) -

Checking the box indicates that you have agreed to the following:

---- Town of Kensington Town Waiver ----

ACKNOWLEDGEMENT OF RISKS. Recreational activities, programs, equipment, and facilities have inherent risks even in a controlled environment. It is impossible to enumerate all of the possible ways in which injuries may occur. Some examples include but are not limited to: (1) misuse of equipment or facilities; (2) physical contact with equipment; (3) failure of the facilities or equipment; (4) mental or physical health problems of myself or others; and (5) negligence of myself or others. I agree and acknowledge that:
The above list is not complete and that other unknown or unanticipated risks may result in bodily injury, property damage, permanent disability, paralysis, death, or other loss for me or for others.
I am, and all other individuals are, responsible for our own safety.
I have responsibilities to discontinue my participation if I believe the conditions are unsafe.
I have no mental or physical problems or limitations that might compromise or affect my ability to participate in recreational activities and recreational programs and use of the equipment, facilities, and property. E. I am fully capable of participating in these activities without causing harm to me or others.
I will follow any and all policies, rules, and regulations as the same may be amended from time to time. G. Individuals are available to answer any questions about the nature and physical demands of these activities and the risks associated with these activities.
There are no assurances of my own safety and I assume all risks involved in my participation. I. My participation or attendance is purely voluntary, and I choose to participate in or attend such activities in spite of, and with complete knowledge of, the risks of injury to me or others.

I ASSUME AND ACCEPT FULL RESPONSIBILITY FOR ALL RISKS IDENTIFIED HERE AND FOR THOSE RISKS NOT IDENTIFIED, AND FOR BODILY INJURY, PROPERTY DAMAGE, PERMANENT DISABILITY, DEATH, PARALYSIS, OR OTHER LOSS SUFFERED BY ME AS A RESULT OF THOSE RISKS, MY OWN NEGLIGENCE OR OTHER CONDUCT, OR THE NEGLIGENCE OF THE RELEASEES.

Phone: (603) 772-5423 Fax: (603) 772-6841 Web: www.town.kensington.nh.us

RELEASE. I HEREBY WAIVE, RELEASE, AND DISCHARGE (AND COVENANT NOT TO SUE) THE TOWN OF KENSINGTON, ITS OFFICIALS, OFFICERS, AGENTS, EMPLOYEES, REPRESENTATIVES, AFFILIATES, VOLUNTEERS, AND ALL OTHER PERSONS OR ENTITIES ASSOCIATED WITH THE TOWN OF KENSINGTON (COLLECTIVELY, THE “RELEASEES”) FROM ALL LIABILITIES, CLAIMS, DEMANDS, LOSSES, DAMAGES, OR CAUSES OF ACTION RELATED TO ANY INJURY TO, OR ILLNESS, DEATH, PERMANENT DISABILITY, OR PARALYSIS OF, ANY PERSON (INCLUDING ME), OR DAMAGE TO ANY PROPERTY (INCLUDING MINE), (WHETHER OR NOT AS A RESULT OF THE NEGLIGENCE OF ANY OR ALL OF THE RELEASEES) RESULTING FROM, ARISING OUT OF, OR IN CONNECTION WITH MY PARTICIPATION IN RECREATIONAL ACTIVITIES AND PROGRAMS, AND/OR MY USE OF TOWN OF KENSINGTON PROPERTY, EQUIPMENT, AND/OR FACILITIES.
INDEMNIFICATION. I HEREBY AGREE TO DEFEND, INDEMNIFY, AND HOLD HARMLESS THE RELEASEES FROM AND AGAINST ANY CLAIM, CAUSE OF ACTION, LIABILITY, OR JUDGMENT (INCLUDING WITHOUT LIMITATION, LEGAL FEES ASSOCIATED WITH DEFENDING SUCH CLAIM), RESULTING FROM, ARISING OUT OF, OR IN ANY WAY RELATED TO MY PARTICIPATION IN RECREATIONAL ACTIVITIES/PROGRAMS AND/OR MY USE OF TOWN OF KENSINGTON PROPERTY, EQUIPMENT, AND/OR FACILITIES.

I have carefully read, understand, and voluntarily sign this Agreement and acknowledge that it shall be effective and binding upon me, my family, my heirs, executors, administrators, and representatives. I agree that if any portion of this Agreement is held to be invalid, the balance of this Agreement shall continue in full force and effect. I agree that a photocopy or facsimile copy of this Agreement, if fully executed, shall have the same force and effect as the original. Nothing in this Agreement shall

be construed as a waiver of any statutory or common law immunity or limitation of liability available to the Town of Kensington, its officials, officers, volunteers, employees, and agents.

I HAVE HAD SUFFICIENT OPPORTUNITY TO READ THIS ENTIRE DOCUMENT AND HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS. I HAVE READ AND UNDERSTOOD IT. I AGREE TO BE BOUND BY ITS TERMS.

---- Alternate Contact/Pickup Agreement ----

Kensington Recreation has my permission to release my child to any of the people listed as Alternate Contacts/Pickups, should I be unable to do so. Kensington Recreation Staff are required to view photo identification before releasing children to any adult. Any changes will have to be submitted, in writing, to the Camp Director at least 24 hours in advance.

---- 2024 Kensington Summer Camp Waiver ----

I give my permission for my child to participate in the Kensington Recreation Committee's Summer Camp Program at the Kensington Town Park, as well as attending the beach activity or off-site substitution, with transportation provided by First Student Busing, Camp Lincoln and/or the Pinnacle. My child has walking permission to KES, Kensington Public Library, and/ or Pinnacle properties when applicable under the direct supervision and accompaniment of approved personnel from the Kensington Recreation Committee's Summer Camp Program at all times. I assume all risks and hazards incidental to the conduct of these activities. I do hereby release and hold harmless the Kensington Recreation Committee, directors, staff counselors, volunteers and anyone connected with the program. In any case of injury to my child, I hereby waive all claims against the organizers and the supervisors of the activities. I likewise release from responsibility any person transporting my child to and from the activities. I hereby give permission for the Kensington Recreation Camp staff to give my child simple first aid when necessary, or in the event of a more serious accident, authorize qualified staff members to administer CPR. In addition, I authorize my child to be transported to a hospital to receive emergency medical treatment. I authorize ambulance/rescue squad attendants to administer such treatment as is medically necessary, and I authorize the hospital to undertake examination and emergency treatment if warranted on behalf of my child.

---- Photo Release Agreement ----

If the "Permission to use Photos" was selected as Yes, I grant the Town of Kensington, its representatives, and employees the right to take photographs of me in connection with the 2023 Summer Camp program. I
also agree that the Town of Kensington has permission to use any program sponsored pictures in which any likeness appears. I authorize the Town of Kensington to copyright, use and publish these photo images in print or electronically.

I agree that the Town of Kensington may use such images with or without my name and for any lawful purpose, including for example such purposes aspublicity, marketing collateral, presentations, print advertising and web content.

Parent Information

Emergency Contact Information

Alternate Contact/Pick-up #1

Alternate Contact/Pick-up #2

Alternate Contact/Pick-up #3

Camper #1

Camper #1 Medical Information

Camper #1 Allergen Information (if Applicable)

Camper #1 Symptom Information (if Applicable)

Camper #1 Medication Procedure Information (If Applicable)

Camper #2

Camper #2 Medical Information

Camper #2 Allergen Information (if Applicable)

Camper #2 Symptom Information (if Applicable)

Camper #2 Medication Procedure Information (If Applicable)

Camper #3

Camper #3 Medical Information

Camper #3 Allergen Information (if Applicable)

Camper #3 Symptom Information (if Applicable)

Camper #3 Medication Procedure Information (If Applicable)

Electronic Signature

Transaction Details