princeton community dances
PRINCETON COMMUNITY DANCES for Adults and Teens with Special Needs with DJ STEVEN KNOX Sponsored by PRINCETON SPECIAL SPORTS and the PRINCETON RECREATION DEPARTMENT
2017-18 SEASON
Dances are from 7 to 9; Spring Formal is from 7 to 9:30; Pool BBQ is from 6:30 to 9:00 Dances (with pizza) & Pool BBQ - $12 [Register by 3 p.m. on the date of event] Spring Formal - $25 [Registration deadline is earlier of April 13 or when we reach capacity]
September 15
February 9
October 6
March 16
November 3
April 13
December 15
May 4 SPRING FORMAL
January 19
June 1 POOL BBQ
ALL DANCES ARE IN THE JOHN WITHERSPOON SCHOOL GYM, 217 WALNUT LANE IN PRINCETON EXCEPT: May 4 SPRING FORMAL Suzanne Patterson Center, 45 Stockton Street in Princeton June 1 POOL BBQ Princeton Community Pool, 380 Witherspoon Street in Princeton
To register, go to https://register.communitypass.net/princeton. Follow online instructions to set up, or use existing, account. Dances are under Special Needs Programs. You can also register in person at the Recreation Department; by mail; or by calling (609) 921-9480 (you’ll need to pay with a debit or credit card). You must be at least 13 to attend. Cancellations for credit must be received by the applicable registration deadline. Fee assistance is available. For more information, please visit princetonspecialsports.com or princetonrecreation.com. Although the dances are chaperoned by adults with the assistance of student volunteers, we cannot provide lowratio support. We therefore may require participants to be accompanied by an adult support person if we determine it is in the best interests of the participant or other attendees.
PRINCETON COMMUNITY DANCES OFFLINE REGISTRATION COMPLETE AND MAIL OR BRING WITH FEES AND FULLY COMPLETED EMERGENCY MEDICAL FORM AND RECREATION DEPARTMENT WAIVER TO THE PRINCETON RECREATION DEPARTMENT, 380 WITHERSPOON STREET, PRINCETON, NJ 08540. NAME ________________________________________________________________________ ADDRESS ______________________________________________________________________ DATE OF BIRTH _____________________ PHONE _____________________________________ EMERGENCY PHONE _____________________________________________________________ EMAIL ADDRESS ________________________________________________________________ PLEASE PRINT VERY CLEARLY
WILL A SUPPORT PERSON BE STAYING WITH YOU AT THE DANCES?
YES
□
CHECK DATE(S) YOU WILL ATTEND September 15 ($12)
□
February 9 ($12)
□
October 6 ($12)
□
March 16 ($12)
□
November 3 ($12)
□
April 13 ($12)
□
December 15 ($12)
□
May 4 FORMAL ($25)
□
January 19 ($12)
□
June 1 BBQ ($12)
□
TOTAL ENCLOSED: $ ____________
NO
□
EMERGENCY MEDICAL FORM PARTICIPANT NAME ___________________________________________________ DATE OF BIRTH _____________________________ FULL ADDRESS ___________________________________________________________________________________________________________ EMAIL _________________________________________________ TELEPHONE _____________________________________________________ IMPORTANT: TELEPHONE NUMBER(S) WHERE AN ADULT RESPONSIBLE FOR THIS PARTICIPANT CAN BE REACHED DURING EACH DANCE IN CASE OF AN EMERGENCY 1 ______________________________________________________
2 _____________________________________________________________
MEDICAL INFORMATION ALL DRUG, FOOD, AND OTHER ALLERGIES (INDICATE WHETHER PARTICIPANT CARRIES AN EPIPEN) ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Participants and their guardians, not PSS/PRD staff or volunteers, are responsible for making sure participants avoid foods to which they are allergic. Foods may contain, or may have been prepared around, peanuts or other potential allergens.
PHYSICAL, MENTAL HEALTH, COGNITIVE DIAGNOSES/CONDITIONS (LIST ALL) _________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ALL MEDICATIONS BEING TAKEN ______________________________________________________________________________________ ______________________________________________________________________________________________________________________________ PHYSICIAN’S NAME & PHONE __________________________________________________________________________________________ RESTRICTED ACTIVITIES, if any ________________________________________________________________________________________ PARENT/GUARDIAN INFORMATION NAME(s) _______________________________________________ RELATIONSHIP ________________________________________________ FULL ADDRESS ___________________________________________________________________________________________________________ CELL PHONE (______) _____________________________________ OTHER PHONE (______)_____________________________________ EMAIL _____________________________________________________________________________________________________________________ I AM LEGALLY RESPONSIBLE FOR THE PARTICIPANT NAMED ABOVE. HE/SHE DOES NOT HAVE ANY PHYSICAL, COGNITIVE, MENTAL HEALTH, OR OTHER CONDITION THAT WOULD PREVENT, OR CREATE A SPECIAL RISK IN, HIS/HER PARTICIPATION IN THE PRINCETON COMMUNITY DANCES. I CONFIRM THAT I HAVE PROVIDED ACCURATE AND COMPLETE MEDICAL AND MEDICATION INFORMATION. I UNDERSTAND THAT THE DANCES ARE NOT STAFFED WITH MEDICAL PERSONNEL AND AUTHORIZE THE ADULT STAFF OF THE DANCES TO CONSENT TO MEDICAL TREATMENT IN THE EVENT OF AN EMERGENCY. I CONSENT TO THE USE OF THIS PARTICIPANT’S NAME AND PHOTO IN ARTICLES OR SOCIAL MEDIA POSTS ABOUT THE DANCES, PRINCETON SPECIAL SPORTS, OR THE PRINCETON RECREATION DEPARTMENT. I RELEASE AND HOLD THE PRINCETON RECREATION DEPARTMENT; PRINCETON SPECIAL SPORTS; THEIR RESPECTIVE OFFICERS, TRUSTEES, VOLUNTEERS, AND EMPLOYEES; AND ALL OF THE VOLNTEERS AND STAFF OF THE DANCES HARMLESS FROM ANY AND ALL CLAIMS WHATSOVER.
SIGNATURE _______________________________________________________________________ DATE _______________________________ PRINT NAME _____________________________________________________________________________________________________________
PRINCETON RECREATION COMMISSION/PRINCETON RECREATION DEPARTMENT AGREEMENT TO PARTICIPATE, ACKNOWLEDGEMENT OF RISK, AND WAIVER OF ALL CLAIMS
I recognize that there are certain risks of physical injury inherent with my participation in this program, and in order to minimize these risks I agree to obey all rules and regulations, follow all safety procedures, and to obey any and all instructors, assistant instructors and staff members assigned to this program. I certify that I am in proper physical condition for safe participation in this program, and agree that it is incumbent upon me to immediately inform a program instructor, assistant instructor or staff members should my condition change at any time during my participation in this program. Because the Princeton Recreation Commission-Recreation Department is a public entity, I recognize that my ability to recover damages from the Princeton Recreation Commission-Recreation Department and its officers, agents, servants and employees as a result of injury, death or other loss I may suffer due to my participation in this program may be limited by the provision of the Tort Claims Act (N.J.S.A. 59:1-1, et seq.). By signing below, I acknowledge that I understand my and/or my family’s responsibilities as outlined above.
Signature _____________________________________________________________________________ Parent or Legal Guardian Signature ________________________________________________________ Participant Name (print) _________________________________________________________________ Date _________________________________________________________________________________
Rev. 5/13
2017-18 SEASON
Dances are from 7 to 9; Spring Formal is from 7 to 9:30; Pool BBQ is from 6:30 to 9:00 Dances (with pizza) & Pool BBQ - $12 [Register by 3 p.m. on the date of event] Spring Formal - $25 [Registration deadline is earlier of April 13 or when we reach capacity]
September 15
February 9
October 6
March 16
November 3
April 13
December 15
May 4 SPRING FORMAL
January 19
June 1 POOL BBQ
ALL DANCES ARE IN THE JOHN WITHERSPOON SCHOOL GYM, 217 WALNUT LANE IN PRINCETON EXCEPT: May 4 SPRING FORMAL Suzanne Patterson Center, 45 Stockton Street in Princeton June 1 POOL BBQ Princeton Community Pool, 380 Witherspoon Street in Princeton
To register, go to https://register.communitypass.net/princeton. Follow online instructions to set up, or use existing, account. Dances are under Special Needs Programs. You can also register in person at the Recreation Department; by mail; or by calling (609) 921-9480 (you’ll need to pay with a debit or credit card). You must be at least 13 to attend. Cancellations for credit must be received by the applicable registration deadline. Fee assistance is available. For more information, please visit princetonspecialsports.com or princetonrecreation.com. Although the dances are chaperoned by adults with the assistance of student volunteers, we cannot provide lowratio support. We therefore may require participants to be accompanied by an adult support person if we determine it is in the best interests of the participant or other attendees.
PRINCETON COMMUNITY DANCES OFFLINE REGISTRATION COMPLETE AND MAIL OR BRING WITH FEES AND FULLY COMPLETED EMERGENCY MEDICAL FORM AND RECREATION DEPARTMENT WAIVER TO THE PRINCETON RECREATION DEPARTMENT, 380 WITHERSPOON STREET, PRINCETON, NJ 08540. NAME ________________________________________________________________________ ADDRESS ______________________________________________________________________ DATE OF BIRTH _____________________ PHONE _____________________________________ EMERGENCY PHONE _____________________________________________________________ EMAIL ADDRESS ________________________________________________________________ PLEASE PRINT VERY CLEARLY
WILL A SUPPORT PERSON BE STAYING WITH YOU AT THE DANCES?
YES
□
CHECK DATE(S) YOU WILL ATTEND September 15 ($12)
□
February 9 ($12)
□
October 6 ($12)
□
March 16 ($12)
□
November 3 ($12)
□
April 13 ($12)
□
December 15 ($12)
□
May 4 FORMAL ($25)
□
January 19 ($12)
□
June 1 BBQ ($12)
□
TOTAL ENCLOSED: $ ____________
NO
□
EMERGENCY MEDICAL FORM PARTICIPANT NAME ___________________________________________________ DATE OF BIRTH _____________________________ FULL ADDRESS ___________________________________________________________________________________________________________ EMAIL _________________________________________________ TELEPHONE _____________________________________________________ IMPORTANT: TELEPHONE NUMBER(S) WHERE AN ADULT RESPONSIBLE FOR THIS PARTICIPANT CAN BE REACHED DURING EACH DANCE IN CASE OF AN EMERGENCY 1 ______________________________________________________
2 _____________________________________________________________
MEDICAL INFORMATION ALL DRUG, FOOD, AND OTHER ALLERGIES (INDICATE WHETHER PARTICIPANT CARRIES AN EPIPEN) ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Participants and their guardians, not PSS/PRD staff or volunteers, are responsible for making sure participants avoid foods to which they are allergic. Foods may contain, or may have been prepared around, peanuts or other potential allergens.
PHYSICAL, MENTAL HEALTH, COGNITIVE DIAGNOSES/CONDITIONS (LIST ALL) _________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ALL MEDICATIONS BEING TAKEN ______________________________________________________________________________________ ______________________________________________________________________________________________________________________________ PHYSICIAN’S NAME & PHONE __________________________________________________________________________________________ RESTRICTED ACTIVITIES, if any ________________________________________________________________________________________ PARENT/GUARDIAN INFORMATION NAME(s) _______________________________________________ RELATIONSHIP ________________________________________________ FULL ADDRESS ___________________________________________________________________________________________________________ CELL PHONE (______) _____________________________________ OTHER PHONE (______)_____________________________________ EMAIL _____________________________________________________________________________________________________________________ I AM LEGALLY RESPONSIBLE FOR THE PARTICIPANT NAMED ABOVE. HE/SHE DOES NOT HAVE ANY PHYSICAL, COGNITIVE, MENTAL HEALTH, OR OTHER CONDITION THAT WOULD PREVENT, OR CREATE A SPECIAL RISK IN, HIS/HER PARTICIPATION IN THE PRINCETON COMMUNITY DANCES. I CONFIRM THAT I HAVE PROVIDED ACCURATE AND COMPLETE MEDICAL AND MEDICATION INFORMATION. I UNDERSTAND THAT THE DANCES ARE NOT STAFFED WITH MEDICAL PERSONNEL AND AUTHORIZE THE ADULT STAFF OF THE DANCES TO CONSENT TO MEDICAL TREATMENT IN THE EVENT OF AN EMERGENCY. I CONSENT TO THE USE OF THIS PARTICIPANT’S NAME AND PHOTO IN ARTICLES OR SOCIAL MEDIA POSTS ABOUT THE DANCES, PRINCETON SPECIAL SPORTS, OR THE PRINCETON RECREATION DEPARTMENT. I RELEASE AND HOLD THE PRINCETON RECREATION DEPARTMENT; PRINCETON SPECIAL SPORTS; THEIR RESPECTIVE OFFICERS, TRUSTEES, VOLUNTEERS, AND EMPLOYEES; AND ALL OF THE VOLNTEERS AND STAFF OF THE DANCES HARMLESS FROM ANY AND ALL CLAIMS WHATSOVER.
SIGNATURE _______________________________________________________________________ DATE _______________________________ PRINT NAME _____________________________________________________________________________________________________________
PRINCETON RECREATION COMMISSION/PRINCETON RECREATION DEPARTMENT AGREEMENT TO PARTICIPATE, ACKNOWLEDGEMENT OF RISK, AND WAIVER OF ALL CLAIMS
I recognize that there are certain risks of physical injury inherent with my participation in this program, and in order to minimize these risks I agree to obey all rules and regulations, follow all safety procedures, and to obey any and all instructors, assistant instructors and staff members assigned to this program. I certify that I am in proper physical condition for safe participation in this program, and agree that it is incumbent upon me to immediately inform a program instructor, assistant instructor or staff members should my condition change at any time during my participation in this program. Because the Princeton Recreation Commission-Recreation Department is a public entity, I recognize that my ability to recover damages from the Princeton Recreation Commission-Recreation Department and its officers, agents, servants and employees as a result of injury, death or other loss I may suffer due to my participation in this program may be limited by the provision of the Tort Claims Act (N.J.S.A. 59:1-1, et seq.). By signing below, I acknowledge that I understand my and/or my family’s responsibilities as outlined above.
Signature _____________________________________________________________________________ Parent or Legal Guardian Signature ________________________________________________________ Participant Name (print) _________________________________________________________________ Date _________________________________________________________________________________
Rev. 5/13
