Welcome to Playground Days ! - City of Cortez
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Welcome to Playground Days !
We are excited for your child to get involved in our programs!
Attached are several forms that must be filled out BEFORE your child
can attend. Please provide your child with a water bottle every day.
Hydration is very important when you’re having this much fun!
We will still be following COVID protocols this summer. This means that
we will be doing a temperature check at drop off and at lunch time. We
will also require children wear a mask when we are in the building and
in the vans/bus for transportation. Please make sure your child’s mask
is labeled with their name. W e had a lot of m ask s left and lost
last year.
Thank you so much for your cooperation in this regard. We look
forward to meeting you soon!
PGD StaffCITY OF CORTEZ PLAYGROUND DAYS
REGISTRATION FORM
Office Use Only: Imm______
CHILD’S INFORMATION
Full Name: Nickname:
Date of birth: School: Gender: Male/Female
Current address:
City: State: ZIP Code:
PARENT/GUARDIAN INFORMATION
Name of Parent/Guardian: Name of Parent/Guardian:
Cell Phone: Cell Phone:
Employer: Employer:
Employer Address: Employer Address:
Employer Phone: Employer Phone:
EMERGENCY CONTACT AND AUTHORIZED PICKUP
Emergency Contact Name:
Address: Phone:
City: State: ZIP Code:
Relationship: Authorized to Pick up Child? Yes/No
Emergency Contact Name:
Address: Phone:
City: State: ZIP Code:
Relationship: Authorized to Pick up Child? Yes/No
Additional Person Authorized to pick up child:
Relationship: Phone:
City: State: ZIP Code:
Additional Person Authorized to pick up child:
Relationship: Phone:
City: State: ZIP Code:
MEDICAL INFORMATION
Primary Doctor: Primary Dentist:
Office Phone: Office Phone:
Office Address: Office Address:
Known Allergies/Reactions:
Chronic Illnesses/Special Needs:
Medications:
AUTHORIZATION FOR EMERGENCY MEDICAL CARE AND TRANSPORTATION
In the event of an emergency I hereby give my permission for child care staff to access emergency medical services for my
child, including transport to the nearest health care facility, to receive emergency medical or surgical care and treatment. I
understand that the City of Cortez has no accident insurance. I further hold the city of Cortez, its directors, officers, and agents
harmless from any claim I or said child may have as a result of said participation. It is understood that reasonable effort will be
made to locate me or my spouse prior to any medical or dental treatment, and I accept the expense of care and transport.
Parent/Guardian Signature: Date:CITY OF CORTEZ PLAYGROUND DAYS AUTHORIZATION FORM
PERMISSION FOR TRIPS
I give permission for my child to go on trips away from the premises of the child care facility, in the company of a responsible
adult, whether on foot or by vehicle.
Parent/Guardian Signature: Date:
PERMISSION FOR PARTICIPATION IN ACTIVITIES
(INCLUDING MOVIE AND VIDEO DAYS)
I give permission for my child to participate in program activities, except for the following
________________________________________________________________________
Parent/Guardian Signature: Date:
WHEEL DAY AUTHORIZATION
I __________________________, understand that wheel day poses inherent risks. I also understand that if my child
participates in wheel day that I will provide him/her with the necessary safety equipment needed for that particular activity. If
the necessary safety equipment is not provided, my child will not be able to participate. Playground Days staff will ensure that
all safety equipment will be worn at all times and will supervise each child during this activity.
I also give permission for my child, ____________________, to use either a program bicycle or helmet in the instance that my
child’s equipment was forgotten or not available for use. I understand the inherent risks associated with the use of the
equipment and that it may not always be available to my child during the program.
Bicycle, Skateboard, Scooter, Hoverboard
Roller Blades or Roller Skates
Helmet
Helmet
Tennis Shoes (recommended)
Elbow Pads
Elbow Pads (recommended)
Knee Pads
Knee Pads (recommended)
Parent/Guardian Signature: Date:
SUN PROTECTION
Prior to outside play, the center must obtain a parent or guardian’s written authorization and instructions for applying
sunscreen or use of another form of parent or guardian approved sun protection to their children’s exposed skin. A doctor’s
permission is not needed to use sunscreen at the center.
The center must apply sunscreen, have the parent or guardian apply sunscreen, or use another form of parent or guardian
approved sun protection for children prior to children going outside. Sunscreen must be reapplied as directed by the
product label.
When supplied for an individual child, the sunscreen must be labeled with the child’s first and last name.
If sunscreen is provided by the center, parents must be notified in advance in writing of the type of sunscreen the center
will use.
Children over four (4) years of age may apply sunscreen to themselves under the direct supervision of a staff member
If you DO want your child to have sunscreen applied If you DO NOT want your child to have sunscreen applied
I give permission for ______________________ to have I do not want my child ___________________ to have
sunscreen applied while at Playground Days, I understand that sunscreen applied while at playground days.
NO_AD Sun Care 50 brand of sunscreen w ill be used.
Parent/Guardian Signature Date Parent/Guardian Signature Date
PHOTO RELEASE
I give permission for photos of my child, _____________________, to be taken and used throughout the summer. I under-
stand that photographs may be used for printed publication, online publication, presentations, websites, and social media. I
also understand no compensation shall become payabe to me by reason of such use.
Parent/Guardian Signature: Date:CITY OF CORTEZ PLAYGROUND DAYS RULES
Children will treat each other with respect
Children will treat Playground Days Counselors with respect.
Children will treat all public and personal property with respect.
Please initial below to verify you have read and understand the information presented.
You must not send your child to Playground Days if they have a communicable disease, (i.e. strep throat,
flu, etc.). If your child becomes ill at Adventure Club, you will be called to pick them up.
Parents must sign the child out daily. This gives staff opportunity to discuss upcoming events, hand out
permission slips, etc.
Parents must provide a written note if someone other than themselves will be picking up their child.
Please be prompt in picking up your child. A late fee of $2 per minute will be charged.
Please call the Recreation Center no later than 7:00am to notify us if your child will be absent. This allows
space for drop in children. We will issue credit for another day later in the school year. No credit will be
issued if you fail to notify us by 7:00am the day of the absence.
Playground Days will enforce the discipline contract. The report form will be signed and dated by the
guardian and Playground Days supervisor.
Sunscreen will be applied daily for all campers. SPF of greater than 30 will be used. Please let staff know if
your child has any skin allergies.
When weather is bad, and children are unable to play outside, children may watch movies/television rated
PG or below.
Children are not to bring personal belongings such as, game boys, cd players, money, or any other valuable
item they might have. The City if Cortez Parks and Recreation Department is not responsible for lost or
stolen items.CITY OF CORTEZ PLAYGROUND DAYS
PARENT QUIESTIONNAIRE
Please help us make your child’s experience at Adventure Club as fun and educational as possible.
1. What does you child like? (hobbies, interests, food, etc)
2. What does your child dislike?
3. Does your child have allergies? (food/other)
4. Is there anything about your child’s medical history that you feel we should know?
5. What are you expectations of the program and program staff?
6. Is there anything that you would like us to know that may help us give your child a positive experience at Playground Days?
If you have any suggestions for activities or field trips, we would greatly appreciate them.You can also read
