Summer Camp Secure Registration Form

Please fill out ALL required fields. Forms that are not properly completed may affect your registration status.

Completion of this online registration form is not a guarantee that space is available in this program or that your child has obtained a spot.

* = required fields

Household Information
* Child's Full Name:
* Street Address:
* City, State, Zip: ,
* Home Phone #:
   Gender: Male     Female
* Age:
* Date of Birth (mm/dd/yy):
* Grade in September '17:
* T-Shirt Size: Youth: SM     MED     LG
Adult:   SM     MED     LG
* Registering Guardian's Email:
* Guardian #1 Name:
* Guardian #1 Cell Phone:
* Guardian #1 Work Phone:
   Guardian #2 Name:
   Guardian #2 Cell Phone:
   Guardian #2 Work Phone:
* Insurance Company Name:
* Insurance Account Number:
* Emergency Contact:
* Emergency Phone:
* Relation to Child:
Check Off Desired Camp Sessions
Adventure Camp Entering Gr. 6-8
ACME Fun Camp Entering Gr. 3-5
ACME Jr. Camp Entering Gr. 1-2
A.M. TYKES   (M-Tu-W) Ages 3-5
A.M. TYKES   (Mon-Fri) Ages 3-5
FULL DAY TYKES   (M-Tu-W) Ages 4 & 5
FULL DAY TYKES   (Mon-Fri) Ages 4 & 5
Check Off Your Extended Care Needs, If Any
Early Care:    ($50/session OR $5/day for Tykes) 8:00-9:00AM
Late Care:     ($80/session OR $8/day for Tykes) 3:00-4:00PM
Help Us Get to Know Your Child, Please Take A Moment to Answer the Following...
Food Allergies:
Scholarship Fund
We believe that no child should be excluded due to inability to pay. If you would like to help a child attend camp, please consider adding $1 (or more!) to your balance. Thank you!
Amount added:
Summer Camp Registration Information
Balance Information: SEND NO MONEY AT THIS TIME. Once the lottery is complete you will be notified about which session(s) are confirmed or wait listed and the deposit amount due (based on $100 per session, per child). No deposit will be required for wait listed sessions. A deadline for receipt of the deposit will be due in March, 2017. Deposit will be refunded from your balance. Session 1 balance is due April 19, Session 2 balance is due May 17, Session 3 balance is due June 14, Session 4 balance is due July 12.

Cancellation Fees: The $100 deposit is NOT REFUNDABLE or transferrable to another session if you cancel at any time after registration has been processed. Written confirmation will be sent as soon as your registration is processed. Please allow 3-4 weeks.

Medical Forms: State Law requires current medical records on all campers. Forms will be provided and must be returned NO LATER THAN JUNE 1, 2017. Children will not be allowed to begin camp unless this deadline is met. No refunds will be given for cancellations due to incomplete paperwork.

Non-Residents: Register starting May 1st, if space is available. Please add 20% to the regular session fee.

Waiver of Damages and Release of Claims of Minor Child
I, the parent or legal guardian of a minor child, in consideration of his/her use of property belonging to the City of Beverly, and/or his/her participation in programs, leagues or events sponsored by the City of Beverly, and being aware of the risks associated with such use or participation, hereby release and discharge the City of Beverly, its agents and employees from any and all claims for personal injury or other damages that I might have as such parent or legal guardian, now or in the future, and from any and all claims that my said child may have now, or may acquire in the future, as a result of personal injury or damages that he/she may sustain as a result of his/her participation in any Beverly Recreation Department program, league or event. I agree that pictures taken in connection with the program or event may be used for future promotional purposes. Registration by telephone signifies acceptance of the above listed Waiver of Damages.

*Please acknowledge your understanding and acceptance of the above waiver with a check here: