DC: 292401,501,601/Ext: 292000
TT: 291401,501,601
Town of Bedford Recreation and Parks Department
DAY CAMP: T-Shirt Size: Youth Adult TINY TOTS: Entering K in fall? Yes No
List names of kids to place your child with:
HAMLET: Bedford Village Bedford Hills Katonah
Session: Full Camp Session I Session II
Extended Day: Full Camp Session I Session II
Date of Birth:
Grade entering in
Name of School:
IMMUNIZATION RECORDS (exact dates i.e. 4/6/15) Doctor signed copy must also accompany registration
Measles/Mumps/Rubella (MMR)
Varicella (Chickenpox)
General Release: The undersigned hereby releases the town of Bedford, its Town Board, Recreation & Parks Department, employees and
volunteers thereof of any responsibilities should an accident or injury occur to the above named participant as a result of participation in the Bedford
Day Camp/Bedford Tiny Tot program. In the event of injury/illness, if I cannot be reached, I give permission for my child to be taken for evaluation
& treatment at a hospital for needed care. I also give permission for my child to participate in all camp activities: swim at the town pool; participate
in out-of-camp trips that may include aquatic amusement activities and swimming; be taken by bus to the rain location, trips & the Day Camp
Carnival; have photos taken during events & permission for the department to use them, unless I notify them in writing; carry sunscreen that is
FDA approved for OTC use. I understand that once camp starts there is no refund for any reason except a medical one.
Parent/ Guardian Signature: Date:
The name above agrees to all releases and information above
Camper’s Full Name
Home Phone #
Address (street, city, zip)
Phone #
Alt #
Second Contact
Phone #
Alt #
Third Contact
Phone #
Alt #
Doctor's Name:
Phone #:
ID #:
List any known allergies:
Will your child need to have/take any medication
at camp (ex: Benadryl/ Epi Pen/Inhaler)?
Yes** No
Is your child taking any
prescription medicine?
Yes No
** Any camper needing to take/have medication during camp must submit a
Medical Release Form to the Camp Director on the first day your child attends
If yes, list medication:
Reason for medication:
All camps are permitted to operate and are inspected by Westchester Dept. of Health. All inspection reports are on file at the W.C. Health Department,
25 Moore Ave., Mt Kisco, NY 10549
425 Cherry Street, Bedford Hills, NY 10507 (914) 666-7004 ~ Recreation@BedfordNY.gov