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| Upper Providence Township Summer Recreation Program June 24-July 19 8:30 AM to 11:30, Monday -Friday Rose Tree Elementary School Registration is now open. Children entering kindergarten through fifth grade are eligible to participate in the program and will be grouped according to age. Activities include arts and crafts, drama, sports, story time, and special event days. Please complete the required registration form below and return it to the municipal building. Registration forms may be dropped off or mailed to 935 North Providence Road, Media, PA 19063. Fee for the four-week program is $125. Please make checks payable to Upper Providence Township. We ask that you drop off your child at the kindergarten wing. Campers should come daily with bottled water, snack and sunscreen applied. If you have any questions, please contact 610-565-4944. _________________________________________________________________________________ Child’s name: ______________________________ Phone#____________________
Address: ____________________________________________________________
Date of Birth: _______________________ Grade entering September 2013: _______
Health information/Allergies/Medical conditions/Special Needs:
Emergency contacts:
Name: _____________________________ Phone #_______________ relation to child____________ Name: _____________________________ Phone # _______________ relation to child ____________ Doctor' Name:________________________________ Phone #_______________________________
Signature of parent/guardian: _______________________________________
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