Conyngham Park Program 2025 June 16th. July 25th Monday through Friday 9:00 am to 12:00 noon The fee for the program will be $180.00 per child Non-Refundable for 6 weeks, regardless of how many days per week your child attends. Parents must pay for the program at the time of registration. Check payable to Conyngham Borough. Program The program will include a variety of arts and crafts, games, athletics activities, story time, theme days, special events, and guest speakers. We encourage dressing the children appropriately for the outdoor activities. Please have your child/children wear sneakers every day. ABSOLUTELY NO FLIP-FLOPS! Age Requirements Children must be at least five years old (by JUNE 1st) and no older than twelve years of age. NO EXCEPTIONS! BIRTH CERTIFICATE REQUIRED FOR 5 YEAR OLDS ONLYI! Rain In the event of rain, the program may be held in the CVCO Gym depending on availability. More information will be provided at a later date. Hours The program runs from 9:00 am to 12:00 noon. Parents are asked to drop off their children no earlier than 9:00 am and pick them up no later than NOON. All children must be signed in and out daily by an adult. Upon sign-in, the staff will need to know who will be picking your child/children up for that day. Guest Speakers There will be several guest speakers joining us throughout our 6 week program. Lunch/Snack Lunch will be provided Monday through Thursday by the Hazleton Area School District. Children are also welcome to bring their own lunch/snack if they choose to do SO. Swimming Swimming may be scheduled upon availability at the CVCO pool. More information will be provided at a later date. The Abuse and Molestation Policy is available online at conyngnamporougnorg. Our child-staff ratio is 7 to 1. Any concerns/complaints should be addressed with the director the same day. All staff members wear uniforms marked STAFF. CONYNGHAM CHILDREN'S RECREATION PROGRAM REGISTRATION FORM Personal Information Child's Name Address town state zip Birth Date Age Allergies Other Medical Conditions Medication PRIMARY CONTACT Name/Relationship to Child Phone Number Email SECONDARY CONTACT Name/Relationship to Child Phone Number Physician Information Child's Physician Physician's Phone Number Fee: $170.00 NON-REFUNDABLE Rules 1. Pick up children promptly at 12:00 p.m. No exceptions. 2. Please dress in appropriate clothing (shorts, T-shirts, socks and sneakers) 3. Children are expected to listen to the Director and Aides at all times. I have read and understand the rules ofthe Park Program. I give my consent to have my child enter the Conyngham Recreation Program and understand that the cooperating authorities and owners of Whispering Willows Park and the Conyngham Recreation Board will not be held responsible for loss of property, nor injury or death due to accident. Parent's Signature PRESS RELEASE hereby give permission for the Conyngham Recreation Board to use my child's name or photograph in news releases about the Conyngham Park Program in which he/she is participating. Parent's Signature I hereby give my child permission to walk to and from the Park Program on his/her own (must be over age 8). Parent's Signature CON/NGHAMBOROUGH YOUTH PARK PROGRAM PARENTAL PERMISSION TO PARTICIPATE AND RELEASE FROM LIABILITY hereby give permission to my son/daughter, to participate in the Conyngham Borough Youth Program. Park In consideration of being allowed to participate in the Program as administered by the Conyngham, Luzerne County Pennsylvania, including all related events and Borough of bound, acknowledge the following: activities, 1, intending to be legally 1. acknowledge and fully understand that my child will be engaging in various and general recreation that may involve risk of injury, and that there be activities, including sports us or not reasonably foreseeable at this time, may other risks not known to 2. That we assume all ofthe foregoing risks and accept personal injury, responsibility for any damages disability or other implications. following We hereby release, waive and discharge the Borough of Conyngham, Luzerne council, agent, servants, workmen and/or employees from County, its administrators, to person or property caused demands, losses or damages on account of or alleged to be caused, in whole or in part, by negligence or otherwise. injury The undersigned has read the above Waiver and Release and understands the substantial up by signing the same and, not withstanding, they sign it voluntarily. rights may be given Signature give permission for sunscreen/first aid to be applied to my child. Signature give permission for my child to swim at the CVCO pool. Signature Page 1 of2 RELEASE OF LIABILITY FOR MINOR PARTICIPANTS IN CONSIDERATION READ BEFORE SIGNING Conyngham Valley Civic OF my child/ward being allowed to participate in any way in the acknowledges, Organization related events and activities, the appreciates, and agrees that: undersigned The risks ofinjury and illness (ex: communicable diseases Coronavirus diseases) to my child from the activities such as MRSA, influenza, and including the potential for permanent disability involved in these programs are personal discipline and death, and while significant, may reduce these risks, the risks of rules, equipment, and 1. FOR MYSELF, MY SPOUSE, AND serious injury and illness do exist; and, ASSUME ALL SUCH CHILD, I KNOWINGLY AND FREELY FROM THE NEGLIGENCE RISKS, both known and unknown, EVEN IF ARISING responsibility for my child's OF THE RELEASES or others, and assume full 2. participation; and, Iwillingly agree to comply with the program's stated and conditions for participation. IfI observe customary terms and child's readiness for participation any unusual significant concern in my child from the and/or in the program itself, I will remove immediately; participation and bring such attention of the nearest official my and, 3. myself, my spouse, my child, and on behalf of my/our representatives and next ofkin, HEREBY RELEASE heirs, assigns, personal Conyngham Valley Civic Organization; its AND HOLD HARMLESS employees, volunteers, other participants, directors, officers, officials, agents, and if applicable, owners and lessors of sponsoring agencies, sponsors, advertisers, ("Releasees"), WITH RESPECT TO ANY premises used to conduct the event DISABILITY, AND ALL INJURY, child's involvement DEATH, or loss or damage to person or property incident ILLNESS, or participation in these to my FROM THE NEGLIGENCE OF THE programs, WHETHER ARISING fullest extent permitted by law. RELEASEES OR OTHERWISE, to the 4. I, for myself, my spouse, my child, and on behalf of representatives and next ofkin, HEREBY my/our heirs, assigns, personal all the above Releasees from any and all liabilities INDEMNIFY AND HOLD HARMLESS participation in these programs, EVEN IF ARISING incident to my involvement or NEGLIGENCE, to the fullest extent FROM THEIR 5. I, the parent/guardian, assert that I have permitted by law. activity, his/her responsibilities for explained to my child/ward: the risks of the child/ward understands this adhering to the rules and regulations, and that agreement. my I, FOR MYSELF, MY SPOUSE, AND OF LIABILITY AND ASSUMPTION CHILD/WARD, OF HAVE READ THIS RELEASE ITS TERMS, UNDERSTAND THAT RISK AGREEMENT, FULLY BY SIGNING IT, AND SIGN WE HAVE GIVEN UP SUBSTANTIAL UNDERSTAND IT FREELY AND RIGHTS INDUCEMENT. VOLUNTARILY WITHOUT ANY Page 2 of'2 Name of Child/Ward: Name of Parent/Guardian: Parent/Guardian Signature: Date Signed: UNDERSTANDING OR RISK I understand the seriousness of the risks involved in participating in this responsibilities for adhering to rules and regulation, and program, my personal accept them as a participant. Name of Child/Ward: Signature of Child/Ward: Date Signed: