Personal Info

Email: *

Name of Applicant: *

Parent Name: *

Age: *

Gender: *

Street: *

City: *

Zip Code: *

Cell Phone/Home Phone: *

Emergency Contact Name: *

Emergency Contact Number: *

W/C (Walking Consent): *

P/C (Picture Consent):*

Picture: (Max File Size:2MB)

S/S (Shirt Size):*

Youth

S M L

Adult

S M L XL 2XL

ReCaptcha:

Medical Release Form

Name:

Relationship:

Address:

Home Phone:

Cell Phone:

Business Phone:

Alternate Contact:

Alternate Phone:

Email:

Person to contact in case of emergency (Relationship):

Contact Number:

Insurance Policy Name:

Insurance Carrier:

Insurance Company Name:

Insurance Company Telephone Number:

Policy/Group Number:

Physician Name:

Physician Phone Number:

Does your child have any health concerns?

Yes No

If yes, please explain below:

Is your child under medical care?

Yes No

If yes, please explain below:

Does your child currently take any prescribed medications?

Yes No

If yes, please explain below:

List any allergies or reactions to medications, food, plant, animal or insects:

Note any condition that may require special care, medication, etc:

Preferred Hospital (In case of Emergency):

Parent Notification on Administering Medicine

I parent/guardian of , hereby understand that the staff of the Roselle Summer Fun Camp and/or employees of the Borough of Roselle are NOT authorized to administer any medication to my child.

Parent/Guardian Signature:

Date:

Health History

Please list all medications that are currently being used
Inclusive of EpiPen’s and inhalers

Parent's Authorization

To the best of my knowledge, this medical history is correct and complete. I know of no reason to restrict her/his activity and give permission for my child to participate in all activities except as specifically noted herein. In the event neither parent nor designated emergency contact can be reached in an EMERGENCY, I hereby give permission to hospitalize, secure treatment for and to order injection, anesthesia or surgery for my child.I understand that every effort will be made to contact the parent/guardian and/or emergency contact and family physician listed.

Parent/Guardian Name:

Home Phone:

Cell Phone:

Work Phone:

Date:

Parent/Guardian Signature:

Photograph Permission Form

The Roselle Summer Fun Camp program will take pictures during the course of camp. Pictures of our campers participating in activities such as silent reading, arts and crafts and gaming activities will be taken. These pictures are often submitted with articles to the local newspapers for publishing or on television as a method of highlighting the accomplishments of our camp.
Please give your permission to submit your child’s photograph when the occasion

I hereby give permission for the Borough of Roselle to use, in its future brochures and any other publicity/ or broadcasts of any kind, any program pictures, audio or video in which I (or my child/ward) appear.

I DO NOT give permission for the Borough of Roselle to use, in its future brochures and any other publicity/ or broadcasts of any kind, any program pictures, audio or video in which I (or my child/ward) appear.

Campers Name:

Parent’s/Guardian’s Signature:

Date:

Roselle Summer Fun Camp Walking Consent Form

Please sign below if your child has permission to walk to or from camp alone.

I DO NOT / I DO , grant permission for my child to walk to and from (circle one or both) the Roselle Summer Fun Camp Program alone. My child will arrive to camp each day at am and will be dismissed daily at pm.

Home Phone Number:

Cell Phone Number:

Date:

Drop Off and Pickup

All IDs must be presented at the time of pickup.

I hereby give authorization for my child to be dropped off and picked up by the following individuals listed below. I understand if there are any changes in which my child may be released to a different person, I will send written documentation with an explanation of the change, inclusive of name, address and contact number to the camp director. I authorize the following individuals to pick up/drop off my child:

Name:

Address:

Phone Number:

Image: (Max File Size:2MB)

Name:

Address:

Phone Number:

Image: (Max File Size:2MB)

Name:

Address:

Phone Number:

Image: (Max File Size:2MB)

Summer Camp 2025 - Extended Care Options

$25/week per option (Early Drop-Off or Late Pick-Up)

Please check the box(es) for the weeks and care options you are selecting:

Week	Dates	Early Drop-Off ($25)	Late Pick-Up ($25)
Week 1	June 30 – July 3*
Week 2	July 7 – July 11
Week 3	July 14 – July 18
Week 4	July 21 – July 25
Week 5	July 28 – August 1
Week 6	August 4 – August 8
Week 7	August 11 – August 15
Week 8	August 18 – August 22

*Note: Week 1 includes the July 4th holiday and will reflect a 4-day fee structure. Camp will be closed on that day, but early/late care is still available the rest of the week.

To help us ensure your child’s safety, please upload a photo of each person who is authorized to pick up your child.

Roselle Summer Fun Camp 2025

Personal Info

Camp fee per household