Energy Camp Registration
Participant Name ____________________________________________________________
Participant is a ____Member ____Child of Member ____Non-Member
Date of Birth ____________ 2016-2017 School Grade Level _________ Age______
Guardian Name(s): _____________________________ & ___________________________________
Contact Information:
Phone ______________________________ & _____________________________
Email _______________________________ & _____________________________
Address ________________________________________________City______________________Zip__________
Other individuals authorized to pick-up
1)_____________________________ 2)_________________________ 3)_________________________
Pick-up Password: ____________________________________________
How did you hear about us?
Friends____ Employee____ Website____ Internet Search ____ Camp Expo ____ Print Advertising ____
Billing
Method of Payment ____Member House Charge ____CC ____Check ____ Cash
CC Information: Name __________________________________ Exp. ________ Sec# ________
Card Holder Signature ___________________________________Date______________________
Medical
Immunization record and medical clearance must be completed and submitted prior to camp start date.
Physician Name ________________________________________ Contact #________________________________
Medical Concerns/Food Allergies: __________________________________________________________________
Insurance Name & Policy # ________________________________________________________________________
Release Form (to be completed by parent/guardian)
In the event of an emergency requiring medical attention, I hereby grant permission to a physician or hospital personnel
designated by the camp to attend my son/daughter. I expect every effort will be made to contact me in order to receive my
specific authorization before any hospitalization.
Signed: Child’s Name:
Parent/Guardian
Emergency Telephone: Health Insurance Name & Policy #:
*Please attach copy of IMMUNIZATION RECORD and, if applicable, include permission form from
your doctor for any medications needed at camp.
I hereby represent to Club Fit®, its affiliates, shareholders, partners, officers, agents, servants, employees and representatives (collectively, “Club Fit®”), that I (my child) am in good physical condition and
am able to safely participate in Club Fit®’s fitness and sports programs. I acknowledge that Club Fit® urges every participant to have a medical check-up before participating in any of Club Fit®’s programs.
I appreciate the danger of physical stress, strain, or injury and assume whatever risk is involved as a result of my (my child’s) use of the facilitates, equipment or services of Club Fit®.
I hereby release and hold Club Fit® harmless from and against any and all claims, liability, loss, damage, or injury sustained or incurred in connection with my (my child’s) use of the facilities, equipment
or services of Club Fit®, and waive any and all claims against Club Fit® for any damage or liability resulting from or in connection with such use, excepting such damage which may be caused by Club Fit®’s
negligence.
I hereby grant Club Fit® my consent and permission to use my (my child’s) name, portrait, picture, image, statements and comments and to copyright, use and publish the same in whole or in part, in any media
for purposes relating to the business and activities of Club Fit®, including trade or advertising. I hereby release and discharge Club Fit® from any claims and demands arising out of or in connection with such use,
including but not limited to any and all claims for libel or invasion of privacy.
This release, waiver and consent shall be binding upon me and my heirs, legal representatives and assigns.
The NYS Board of Health considers the Club Fit Aquatic Center an “off-site pool” requiring parental permission. I hereby grant permission for my child to swim in the Club Fit Jefferson Valley Aquatic
Center during camp hours.
Print Name
Signature / Parent’s Signature
Jefferson Valley . 600 Bank Road . 914.245.4040 . clubfit.com
2016 Club Fit Energy Camp Registration Form
Please fill-in your camp session rate and activity selection.
Questions? Call 914-­‐250-­‐2731 or email campsjeffersonvalley@clubfit.com.
—10% surcharge for same day registrations—
Check off which camp you are registering for below:
Camp
Week 1
Week 2
Swim
Full Day
Camp
Jun 27–Jul 1
Member
$
301.00
$
241.00
$
60.00
Child of
$
425.00
$
338.00
$
60.00
Non-Member
$
467.00
$
374.00
$
60.00
July 5–8
Week 3
July 11–15
Week 4
July 18–22
July 4th week Swim Lessons
Kinder Camp
Camp +Swim July 4th week
Week 5
Member
$
270.00
$
228.00
Child of
$
351.00
$
293.00
Non-Member
$
381.00
$
317.00
July 25–29
Week 6
Aug 1–5
Week 7
Aug 8–12
Half Day
Week 8
Week 9
Week 10
Camp +Swim July 4th week
Aug 15–19
Member
$
205.00
$
176.00
Child of
$
269.00
$
227.00
Non-Member
$
292.00
$
245.00
Aug 22–26
Aug 29–Sep 2
TOTAL
CIT
Camp
Early Drop Off
July 4th week
Member
$
110.00
$
88.00
5 days
10
15
20
Child of
$
160.00
$
128.00
$50
$100
$150
$200
Non-Member
$
176.00
$
141.00