Brooklyn Winter Camp Registration


*
Denotes required field


Child Information
First name*
Last name*
Date of birth (mm/dd/yy)*
P.S. number*
Room number
Grade number*
Allergies or medical concerns
Home Address*
City/State/Postal Code*
Home phone number*
Parent's Cell phone*

  Would You Like To Register Multiple Children*   Yes  No

Child #2
First Name
Jewish Hebrew Name
Last Name
 Boy  Girl
Date of Birth (MM/DD/YYYY)
P.S. Number
Grade
Child #3
First Name
Jewish Hebrew Name
Last Name
BoyGirl  
Date of Birth (MM/DD/YYYY)
P.S. Number
Grade
 

Payment information

Released Time Winter Camp - *With early bird special 

*Early bird special ends February 10 at 11:59pm

 $185

Sign up for Bus Transportation Service Yes No
Method of Payment*
   
Credit card number
Expiration date
Name on Card
CVV (3-4 digit code on card)

Checks can be made out to : Released Time Program, 824 Eastern Parkway, Brooklyn, NY 11213


Email for confirmation*
How did you hear about the Released Time Camp
Comments


By submitting this form, I agree to the following terms and conditions: I grant permission for my child to participate in all activities, including swimming and trips away from the grounds. I agree that my child may be photographed, and their pictures may be used in future camp promotional materials, including, but not limited to the brochure and the Released Time website. Released Time is not responsible for personal property brought to Released Time. If the child’s conduct is harmful to the best interests of Released Time, the child may be dismissed at the sole discretion of the Director with no refund nor reduction of fee. I hereby give my approval for my child’s participation in any and all activities prepared by Released Time during the selected time. In exchange for the acceptance of said child’s candidacy by Released Time, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Released Time. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected sessions. In case of injury to said child, I hereby waive all claims against Released Time. Including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball, soccer and swimming. As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to Released Time, and its affiliates including Directors, Staff, and Assistants to provide the needed emergency treatment prior to the child’s admission to the medical facility. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

BY ACKNOWLEDGING AND SIGNING YOUR NAME AND INITIALS BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

 Name  Initials