2026 Summer Club Registration

Child's Name (First & Last Name) *

Primary Parent/Guardian's Name (First & Last Name) *

Primary Parent/Guardian Email Address *

Primary Parent/Guardian Phone Number *

Secondary Parent/Guardian's Name (First & Last Name) *

Secondary Parent/Guardian Email Address *

Secondary Parent/Guardian Phone Number *

Which weeks will your child be attending the Summer Club? * All 8 Weeks (6/22/26-8/14/26)
Week 1 (6/22/26-6/26/26)
Week 2 (6/29/26-7/3/26)
Week 3 (7/6/26-7/10/26)
Week 4 (7/13/26-7/17/26)
Week 5 (7/20/26-7/24/26)
Week 6 (7/27/26-7/31/26)
Week 7 (8/3/26-8/7/26)
Week 8 (8/10/26/-8/14/26)

Which weeks will your child need Aftercare? * None
All 8 Weeks (6/22/26-8/14/26)
Week 1 (6/22/26-6/26/26)
Week 2 (6/29/26-7/3/26)
Week 3 (7/6/26-7/10/26)
Week 4 (7/13/26-7/17/26)
Week 5 (7/20/26-7/24/26)
Week 6 (7/27/26-7/31/26)
Week 7 (8/3/26-8/7/26)
Week 8 (8/10/26-8/14/26)

Primary Emergency Contact's Name (First & Last Name) *

Primary Emergency Contact's Phone Number *

Secondary Emergency Contact's Name (First & Last Name) *

Secondary Emergency Contact's Phone Number *

Primary Pick Up Person's Name (First & Last Name) *

Primary Pick Up Person's Phone Number *

Primary Pick Up Person's Relationship to the Child *

Secondary Pick Up Person's Name (First & Last Name) *

Secondary Pick Up Person's Phone Number *

Secondary Pick Up Person's Relationship to the Child *

Tertiary Pick Up Person's Name (First & Last Name) *

Tertiary Pick Up Person's Phone Number *

Tertiary Pick Up Person's Relationship to the Child *

Pediatrician's Name (First & Last Name) *

Pediatrician's Phone Number *

Health Insurance Company *

Health Insurance Member ID Number *

List any food allergies your child has *

List any medical conditions your child has *

List any medications your child is taking *

Will you be providing an Epi Pen to remain at camp? * Yes
No

Will you be providing an Asthma Inhaler to remain at camp? * Yes
No

Do you authorize the Maywood Recreation Department to use their best judgment for emergency treatment and/or sending your child to the hospital for advanced medical treatment if a parent/guardian cannot be reached? * Yes
No

Please check * I hereby agree to indemnify and hold the Borough of Maywood, NJ harmless from any and all liability arising from the use of municipal property.

Enter your full name as the digital signature acknowledging the above information is correct and was entered by the parent/guardian *

Enter Today's Date *