Conrad Weiser Community Pool, Swim Camp
2019 CW Pool Summer Playground Sign-Up Form

CWCA Code of Conduct:

BEFORE YOU REGISTER: All parents, players, guests and volunteers are subject to the CWCA Code of Conduct and must behave accordingly. Participation in any of these events or activities is at the sole discretion of the CWCA and its member clubs. Failure to abide by club rules may result in exclusion from one or all of its member youth sports clubs. Any incidents that are of concern should be reported through appropriate channels: 1st to the coach of your team, 2nd to the member-club officers, and 3rd to the CWCA board.

See also the CWCA Mandated Reporter Information Sheet

Thank you for your help in making CWCA Youth Sports Clubs a success
by setting a good example for our children.



NOTES: All fields are required. Use 'none' or 'n/a' or similar answers for empty fields as needed...
This form will reject any text it suspects to be inline code or scripts to other sites.

NOTE - Registration for Summer Playground will close after Friday 7/1/19
PLEASE CONFIRM MINIMUM REQUIREMENTS BELOW
Participating Child is at least 5 years old this summer? Yes
Participating Child is at least in Kindergarten or a higher grade this coming school year? Yes
Participating Child will not exceed 12 years of age this summer? Yes
Participating Child is a resident of Robesonia Borough Heidelberg Township
Participating Child MUST agree to ALL terms of the Robesonia Playground Policy Agreement
Participant Agrees Yes

PLEASE NOTE -- ALL FIELDS REQUIRED

for empty fields, just enter a dash or "does not apply" as needed...

PLEASE NOTE - registration closes the Friday at the end of the 2nd week of playground
Participating Child First Name
Participating Child Last Name
Participating Child Age on June 1st
Participating Child Street Address
Participating Child City
Participating Child Zip Code
Participating Child Home Phone

PARENT #1 CONTACT INFORMATION
Parent 1 First Name
Parent 1 Last Name
Parent 1 Work Phone
Parent 1 Cell Phone
Parent 1 Email

PARENT #2 CONTACT INFORMATION
Parent 2 First Name
Parent 2 Last Name
Parent 2 Work Phone
Parent 2 Cell Phone
Parent 2 Email
Does your family have a membership to the Robesonia Swimming Pool?
CW Community Pool 2019 Membership Yes No

EMERGENCY CONTACT [ IF PARENTS CANNOT BE REACHED ]
Emergency Contact Name
Emergency Contact Home Phone
Emergency Contact Cell Phone

MEDICAL HISTORY

Please list any medical problems, allergies, and/or medications
your child is currently taking. Please be specific.

Medical Concerns
Family Doctor Full Name
Family Doctor Name of Practice
Family Doctor Phone

PROOF OF INSURANCE
Insurance Company Name
Insurance Company Phone
Insurance Policy Number
Insurance Group ID

AGREEMENT OF WAIVER LIABILITY

I [ signed below ] hereby give permission for my child [ named above ] to attend and participate in the 2019 Summer Playground Program sponsored by the Conrad Weiser Community Pool. I understand that some playground activities involve certain risks and I hereby waive any and all claims against the CW Pool, their agents, employees, or instructors on the behalf of myself or my child, for any accident, injury, or illness that my child may sustain while participating in the above mentioned program.

Parent Authorization
Parent Authorization Date