1. education
2. alumni and reunions

Cicero Youth Bureau,
Parks & Recreation Department
8236 Brewerton Road
Cicero, New York 13039
Phone 315-699-5233
Website https://cicero.recdesk.com
Email [email protected]
Cicero Youth Bureau,
Parks & Recreation Department
Administra ve Office:
Jody L. Rogers
Julie LaFave
Dawn Maurer
Parks & Facili es Maintenance:
Bill Alley
Bill Lawrence
Mike Hogan
Bre Wood
The CanTeen:
Toni’Lyn Brauchle
Rachel Tarr, Contact Community Services
Mica Gonzalez
Joe San maw
8236 Brewerton Road
Cicero, NY 13039
WEBSITE: h ps://cicero.recdesk.com
EMAIL: [email protected]
PHONE: 315‐699‐5233
Cicero Town Board:
Supervisor:
Deputy Supervisor:
Council Members:
Jessica Zambrano
Bill Meyer
Vern Conway
Mike Becallo
Mark Venesky
Dick Cushman
Parks & Recrea on Commission:
Chairperson:
Lori Lake‐Toms
Vice Chairpersons:
Ruth Beasley
Commissioners:
Dan Rayome
Carol Rose
Tom S mson
Cindy VanNamee
Colleen Wickert
Young @ Heart Senior Center:
Judy Dickson
Nancy Noble
Margaret Hauenstein
Town Hall Departments & Numbers:
Assessor:
699‐1410
Comptroller:
699‐2759
Highway:
699‐2745
Jus ce:
699‐8478
Parks & Recrea on (Main Office)
699‐5233
Parks & Recrea on (CanTeen)
699‐1391
Parks & Recrea on (Senior Center) 452‐3298
Police:
699‐3677
Supervisor:
699‐1414
Tax Department:
699‐2756
Town Clerk:
699‐8109
Zoning/Codes:
699‐2201
Register online at h ps://cicero.recdesk.com
Registra on Details
Leisure Plan‐It
Camp Out
Movie in the Park
Library Events
Gus Macker
Summer Concert Series
Cicero Community Fes val
Day Camp/Extended Day Camp
Camp Inven on
Lego Camp
Tennis Lessons
Gymnas cs
Youth Karate
Stand Up Paddleboard/Kayak
ER Lacrosse
Youth and Adult Golf
Senior Center/The CanTeen
Pavilion Rentals
Summer Registra on Form
Day Registra on Form
Day Camp Medical Authoriza on Form
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Call us at 315‐699‐5233
Registering for Programs
How can you register for our programs?
What methods of payment are accepted?
Registra on for most* programs is accepted in
person, through the mail or online at our website
24/7. Registra on Forms can be downloaded at
h ps://cicero.recdesk.com or found at the end of
this brochure.
Payments can be made with cash, check, money
order or major credit card**.
**Please note: All credit card transac ons will be charged a
3%, plus $0.30 convenience/processing fee. This fee cannot
be refunded, even in the instance of a program being
cancelled. If you do not wish to pay this fee, you can s ll
register for all programs with cash, check or money order.
*Excep on when registering for Day Camp
Due to the necessary forms needed for Day Camp,
online registra on cannot be offered. However, all
methods of payment are s ll accepted.
Register online at
Https://cicero.recdesk.com
Stay up to date!
NEW! Text Alerts for Program Cancella ons
We now have the ability to send program
par cipants any up‐to‐the‐minute cancella ons or
other last minute announcements via text. Instant
no fica on that may come in handy when you are
driving to a program that just got cancelled due to
rain!
Leisure Plan‐It Email List Serve
Want the inside scoop on what is coming up in our
department? Fix that by signing up for our “Leisure
Plan‐It” email list serve. Just send an email to
[email protected] with “LEISURE
PLAN‐IT” in the subject line and we’ll gladly add
you. Whenever we have a program announcement,
you’ll be the first to receive it. Plus, there are perks!
We o en send our brochures out early to our email
members as a thank you for being a loyal fan of the
department. It really is the best way to see what we
have to offer for you and your family.
However, you must provide your network carrier
(Sprint, Verizon, etc) and “opt in” in order for us to
enroll you. This service will be used ONLY in case of
last minute announcements and all of your
informa on stays securely with us. To find out more
or to enroll, call us at 699‐5233 or provide the
informa on when registering online.
Department Facebook Page
And should you decide you no longer want to
receive the updates, removing yourself is as simple
as checking a box.
Register online at h ps://cicero.recdesk.com
We post program announcements and pictures of
people enjoying our events at our Facebook page.
Be sure to give our page a “like.” Go to
www.facebook.com/CiceroRecrea on.
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Call us at 315‐699‐5233
Camp Out!
Joseph F. William Memorial Park, Lakeshore Rd
Check In—Saturday, June 20, Starting at 2 pm
Check Out—Sunday, June 21, by Noon
$25 per campsite ($35 for Non Cicero Families)
Last year’s event was a HUGE success and families
raved. Register for a site and see why everyone loved
it!
For one night only, we’re turning Joseph F. William
Memorial Park into a campground. Bring your tent,
sleeping bags and other camping comforts and let us
provide the fun and memories.
All families that register will receive a goodie bag, as
well as meals and snacks as indicated below.
At the end of the day’s fes vi es, we’ll show a movie
on the big 21’ inflatable screen. (See details on next
page.)

Test out Stand Up Paddleboards and Kayaks for just $5

Find out about the latest in outdoor gear with staff
from Wood Creek Ou i ers

Check out various outdoor games for free
Register online at h ps://cicero.recdesk.com
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Call us at 315‐699‐5233
Movie in the Park
Cloudy with a Chance of Meatballs 2
Saturday, June 20 after sunset (approx. 9:15)
Join us for a night under the stars at Joseph F. William
Memorial Park
Cloudy With a Chance of Meatballs 2 will be shown as a
part of the Cicero Camp Out (see previous page), but will be
open to the public. Bring a blanket or camp chairs, snuggle
up, get comfy and be entertained. Patrons are welcome to
bring their own goodies. (Please note: All Town of Cicero
Parks are alcohol‐free.)
In case of inclement weather, the movie will be shown inside
the Recrea on Building. Sea ng will be limited and will be on
a first come, first serve basis.
But FIRST, let’s Dance and have some FUN!
Before the movie, and a er the sun sets just enough
for us to see the screen, we will have some fun on
the screen as we invite everyone to play along to
Just Dance. This was a HUGE hit last year and we all
learned new dance moves.
Also, before the movie, we will have a special enter‐
tainer walking around. So, come early and set up be‐
fore the sun goes down!
Register online at h ps://cicero.recdesk.com
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Call us at 315‐699‐5233
Library Farm Nature Camp
Par cipants in this unique weekly program will
learn about nature, gardening, habitat,
repurposing and sustainability through hands‐on
experience outdoors at Cicero NOPL. Ac vi es
will include tree iden fica on, science
experiments and nature journaling. Be a part of
the growing garden by iden fying plants and
creatures along the way. A er Camp ends, there
will be a chance for par cipants to collaborate
with the Library to design a Nature Walk
highligh ng favorite features.
Where:
Who:
Session:
Time:
Fees:
WHAT ARE WE MISSING??
The Parks & Recrea on Department is in the
early planning stages of working with Wood
Creek Ou i ers in Brewerton to introduce a
variety of outdoor‐themed workshops, seminars
and classes. But, we need to hear from you!!
What kind of programs would you like to see?
Intro to fly fishing? Leave No Trace Ethics?
Camping Essen als? How to Dutch Oven Cook?
Cicero Library
Fi h Grade and up
Friday July 10, 17, 24, 31,
August 7 & 14
10:00 am—11:00 am
FREE, but pre‐registra on required
Limited to 20 par cipants
Contact our department and let us know!
REGISTER BY CALLING THE LIBRARY AT 699‐2032
OR ONLINE AT NOPL.ORG.
Register online at h ps://cicero.recdesk.com
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Call us at 315‐699‐5233
Register online at h ps://cicero.recdesk.com
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Call us at 315‐699‐5233
Summer Concerts
Mark your calendars and pack your blankets, but drive to the new loca on for the 2015 Summer
Concert Series, hosted by the Greater Cicero Chamber of Commerce. This year the en re concert
series is moving to the field behind Sacred Heart Church, located at 8229 Brewerton Road. Just like in
previous years, members of the Chamber will be selling a variety of foods from their concession. Bring
some money, or bring your own snacks.
Check back soon at h ps://cicero.recdesk.com for the final schedule of concerts.
Tuesday, June 23
6:30—8:30 pm
Band TBA
Tuesday, July 7
6:30—8:30 pm
Country Swag
Tuesday, July 21
6:30—8:30 pm
Band TBA
Tuesday, August 4
6:00—8:00 pm
Smokin
New Location in 2015 Field behind Sacred Heart Church
The Summer Concert Series and Cicero Community Fes val are organized by the Greater Cicero
Chamber of Commerce, with assistance from the Cicero Youth Bureau, Parks & Recrea on Department.
For more informa on on either event, visit their website at: www.cicerochamber.com.
Cicero Community
Festival
Friday, June 12 and Saturday, June 13
Sacred Heart Church
This year, the Greater Cicero Community Fes val is marking its 23rd year with the “Let the Good
Times Roll” themed fes val. Friday night will feature the popular Cruise Night, a performance by Ruby
Shooz and midway rides. Saturday will feature midway rides, a Fun Zone, various demonstra ons,
parade at noon, star search compe on, a performance by Le zia and The Z Band and fireworks.
Full details can be found at www.cicerofes val.com
Register online at h ps://cicero.recdesk.com
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Call us at 315‐699‐5233
Day Camp
Registra on for Day Camp begins
May 9. See details below
Every day is a new theme at Cicero Day Camp. Children in our
program make friends, play old games with a new twist, make the
coolest cra s and find great role models in our energe c staff. All
children in the program receive an official “Cicero Day Camp” shirt
(Shirts guaranteed for all children registered by Monday, June 8.)
Who:
Where:
Days:
Time:
Fee:
Children ages 5* to 12
*5 yr olds must currently be enrolled in Kindergarten
Cicero Elementary School
Monday to Friday
8:15 am to 2:15 pm
$80/week ($90 for Non Residents)
Dates of Day Camp
Week 1: June 29 to July 3
Week 2: July 6 to July 10
Week 3: July 13 to July 17
Week 4: July 20 to July 24
Week 5: July 27 to July 31
Week 6: August 3 to August 7
How to Register for Day Camp
EARLY REGISTRATION (RESIDENTS ONLY)* — Saturday, May 9 from 9 am to Noon at the Cicero Town Hall.
OPEN REGISTRATION*—Beginning Monday, May 11, all registra ons will be accepted in person or through the mail.
*REQUIRED FORMS FOR DAY CAMP REGISTRATION: Completed Registra on, Medical Authoriza on Form, Immuniza on
Record, and Proof of Current Kindergarten Enrollment (2014/15 school year) for 5 year olds only. ALL Required forms (see
below) and full payments must be submi ed before space will be saved for a child.
Due to the numerous required forms for Day Camp, Online Registra on is not available for Day Camp or Extended Day Camp.
All registra ons must be completed in person or via mail. Cash, check, money order and major credit cards are accepted.
Extended Day Camp
At 1:45 pm each day, children enrolled in the
Extended Care Program will be picked up from
Cicero Elementary School and transported to
The CanTeen. Space is limited in this program to
19. A healthy snack will be provided to all
children during this program.
Where:
Days:
Time:
Fee:
The CanTeen
Monday to Friday
2:00 pm to 6:00 pm
$45/week
Register online at h ps://cicero.recdesk.com
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Call us at 315‐699‐5233
Camp Invention
Where:
Smith Road Elementary School
Dates:
Mon, July 13 to Fri, July 17
Who:
Children entering 1st through 6th grades
Time:
8:00 am to 2:30 pm
Fee:
$220 ($230 Non Residents)
ALL PARTICIPANTS MUST BE REGISTERED BY
SUNDAY, JUNE 28
Camp Inven on is where BIG ideas
become the next BIG thing! In partnership
with the Na onal Inventors Hall of Fame,
we are bringing this na onally‐acclaimed
program to Cicero. It’s an exci ng
weeklong summer adventure with lessons
that explore connec ons between science,
technology, engineering and innova on.
Par cipants will work together to seek
solu ons to real‐world problems, turn
ordinary into extraordinary and sharpen
cri cal 21st century learning skills while
rota ng through several fascina ng
modules.
For more informa on on Camp Inven on,
go to: www.campinven on.org.
Lego Camp
This weeklong workshop will explore science, technology,
architecture, engineering and art concepts using LEGO.
Par cipants will design, build and light up an en re city
comprising of tall buildings, bridges, roads, parks and
railways and use ba eries, bulbs, wires and switches to bring
their crea ons alive. The possibili es are limited only by the
imagina on. The workshop will fire up your child's
imagina ons and spark crea vity in the form of inspired play
following one of our many themed LEGO builds coupled with
our magical delivery. Our curriculum will provide your child
with an opportunity to design and build LEGO crea ons
working either individually or in groups and par cipate in
challenges, group compe ons, as well as free build me
towards the end of the workshop.
Where:
Dates:
Ages 5‐7:
Ages 8‐14:
Fee:
Joseph F. William Memorial Park
7034 Lakeshore Road
Mon, July 13 to Fri, July 17
9:00 am to 12:00 pm
12:30 pm to 3:30 pm
$100 ($110 Non Residents)
Register online at h ps://cicero.recdesk.com
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Call us at 315‐699‐5233
Tennis Lessons
Tennis Camp with Coach Wojcik
Coach Wojcik’s camp is perfect for both the
beginner and experienced player. A variety of
drills and lessons will be taught. Par cipants are
asked to supply their own racket, however some
are available for those that need it.
Where:
Session 2:
Session 3:
Session 4:
CNS Tennis Courts
Mon, July 6 to Thurs, July 9
Mon, July 13 to Thurs, July 16
Mon, Aug 3 to Thurs, Aug 6
Ages 4‐6:
Ages 7‐11:
Ages 12+:
Fees:
8:30 am to 9:30 am
9:30 am to 12:30 pm
12:30 pm to 3:30 pm
Ages 4‐6; $50 ($60 Non Residents)
Ages 7+; $70 ($80 Non Residents)
Gymnastics
This is an exci ng program to work on
progressions and beginner gymnas c skills on
vault, bars, beam, floor and trampoline/tumble
trak for both boys and girls. Par cipants will
develop strength, flexibility and coordina on
while learning new gymnas cs skills. As they
learn new skills, gymnas cs will be fun and
exci ng along with the added benefit of
increased self‐esteem.
Where:
Session:
Mondays:
Mondays:
Thursdays:
Saturdays:
Fees:
Blaze Gymnas cs
7 weeks, beginning July 13
10:00 am to 11:00 am
3:30 pm to 4:30 pm
1:00 pm to 2:00 pm
12:00 pm—1:00 pm
$85 ($95 Non Residents)
$5 discount for siblings
Tennis Camp with Coach Cary
This four day camp with Coach Cary includes
instruc on, drills, fitness and match play. The
camp is intended to accelerate the rate of
improvement for players that intend to compete
on a high school team or tennis tournament.
Par cipants will use specialized equipment for
training.
Where:
Session 1:
Who:
Girls:
Boys:
Fee:
Registra on is open for all
programs listed on this page!
Youth Karate
Your child is number one at Karate John’s. In
these classes, they will bring out the best in your
child’s focus, self esteem and confidence, while
reinforcing skills needed for their safety in life. All
new par cipants receive a free uniform with
registra on. Par cipants can select up to 2 class
mes per week, according to their age group.
Registra on is on an ongoing basis and each
session lasts 6 weeks from enrollment.
Where:
Session:
Ages 4‐6:
Ages 7‐12:
Fees:
Register online at h ps://cicero.recdesk.com
CNS Tennis Courts
Mon, June 29 to Thurs, July 2
Players intending to try out for HS
8:00 am to 10:00 am
10:00 am to 12:00 pm
$60 ($70 Non Residents)
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Karate John’s in Walmart Plaza
Ongoing.
6 weeks from registra on date
Mon/Wed 6:00 pm—6:30 pm
Tues/Thurs 5:30—6:00 pm
Sat 9:30—10:00 am
Mon/Wed 6:30—7:00 pm
Tues/Thurs 4:30—5:00 pm
Sat 10:00—10:30 am
$69 ($79 Non Residents)
Call us at 315‐699‐5233
Stand Up Paddleboard & Kayak Lessons
Ever want to try Stand Up Paddleboarding and Kayaking, but didn’t want to invest too much money
or me at first? These highly discounted, one day sessions are a perfect way to try it out or prac ce
skills you already have. Par cipants are welcome to sign up more than once at this introductory rate.
EVENING PADDLEBOARD OR KAYAK LESSONS
Where:
Joseph F. William Park
Lakeshore Road
Who:
Ages 8 and up
Time:
5:00 pm to 7:00 pm
Dates:
Wednesdays (Choose one)
May 27, June 3, June 10, June 17,
June 24, July 1
Fees:
$30 ($40 Non Residents)
EARLY MORNING PADDLEBOARD LESSONS
Where:
Joseph F. William Park
Lakeshore Road
Who:
Ages 8 and up
Time:
6:00 am to 8:00 am
Dates:
Tuesdays or Thursdays (Choose One)
June 2, June 4, June 9, June 11
Fees:
$30 ($40 Non Residents)
ER Lacrosse
ER Lacrosse is an introductory lacrosse program for girls and boys ages 4 to 8. No pads and helmets
are required. All drills are done with a so lacrosse ball in a fun and exci ng manner. Parents are
encouraged to par cipate, while ER Lacrosse instructors lead a variety of new drills to introduce to
the children. Three packages are offered for new and returning par cipants to choose from.
Who:
Where:
Session 1:
Session 2:
Fees:
Children ages 4 to 8
Plank Road Park
Mon, July 6 to Fri, July 10
2:45 pm to 3:45 pm
Mon, July 27 to Fri, July 31
9:00 am to 10:00 am
$65—S ck Package
$65—Pinny Package
$45—Non S ck Package
(Non Residents add $10)
SƟck Package—1 sƟck, 2 soŌ lacrosse ball, 1 water
ball and ER giŌ.
Pinny Package—1 pinny, I soŌ lacrosse ball, 1
water ball and ER giŌ
Basic Package—1 soŌ lacrosse ball, 1 water boƩle
and ER giŌ
Register online at h ps://cicero.recdesk.com
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Call us at 315‐699‐5233
Youth & Adult Golf
Local legend Golf Pro Chuck
Jonick
is
again
teaching
affordable golf lessons in Cicero.
It
is
recommended
that
par cipants supply their own
clubs, but it is not required.
Sessions are iden cal and is not
recommended
for
youth
par cipants to sign up for more
than one session per summer.
Addi onally, there will be a $4/
bucket of balls fee per week.
YOUTH LESSONS
Where:
Cicero Golf Center, Route 11
Who:
Ages 6 to 16
When:
Sat for five weeks
Time:
3:00 pm to 4:00 pm
Session 1:
May 9 to June 6
Session 2:
June 27 to July 25
Fees:
$42 ($52 Non Residents)
ADULT LESSONS
Where:
Cicero Golf Center, Route 11
Who:
Ages 17+
When:
Weds or Sun for five weeks
Time:
6:00 pm to 7:00 pm
Session 1:
Begins week of May 6
Session 2:
Begins week of June 24
Fees:
$49 ($59 Non Residents)
$42 for Senior Ci zens
Senior Center
The CanTeen
5924 Lathrop Drive
315-452-3298
6046 Route 31
315-699-1391
The award‐winning Cicero Senior Center hosts
a variety of programs, trips and more on a
regular basis. Some members come to
compete in the billiards room, others come for
the affordable, nutri ous meals… but almost
all come for the socializa on. Membership is
free for all Cicero Residents ages 55 and older.
And a steal at just $30/annually for Non Cicero
Residents. To find out more about the Center,
stop by for a visit.
The CanTeen shuts down most of the summer
to go on the road around the state! Teens
entering 8th –12th grades in the fall are
welcome to a end any trip, but some fill very
quickly. To find out more about The CanTeen,
visit their website at www.canteencny.com.
Register online at h ps://cicero.recdesk.com
Tentative Summer Trips:





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Enchanted Forest
Darien Lake
Sea Breeze
NYS Fair
NY Yankee Game
Call us at 315‐699‐5233
Planning a Party?
We may have just the pavilion or gazebo for you! We have facili es in most of our parks that are
perfect for any type of gathering. Call us today and we’ll discuss all of the details and find what is best
for you. Only $75 for Cicero Residents for the en re day! ($100 for Non Cicero Residents)
List of Facili es
Central Park—1 pavilion
Gateway Park—1 pavilion
Plank Rd Park—1 gazebo
Sheldon Memorial—1 pavilion
Skyway Park—1 pavilion
William Park—3 pavilions
OTHERS
William Park—Wedding Gazebo and
RecreaƟon Building. Separate rules and
fees apply.
FaciliƟes can be rented online at
hƩps://cicero.recdesk.com
Register online at h ps://cicero.recdesk.com
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Call us at 315‐699‐5233
Town of Cicero Youth Bureau, Parks & Recrea on, 8236 Brewerton Road, Cicero, NY 13039
h ps://cicero.recdesk.com; 315‐699‐5233; [email protected]
2015SummerRegistrationForm
Please use separate DAY CAMP Registra on Form to register your child for Day Camp.
Parent/Legal Guardian:
Address:
City:
Zip:
Home Phone:
Cell Phone:
Email Address:
Emergency Contact Name:
Emergency Contact Number:
1. Par cipant Name:
Date of Birth:
Age:
Session:
Gender:
1
2
3
Program:
Day/Time:
2. Par cipant Name:
Date of Birth:
Age:
Session:
Gender:
1
2
3
Program:
Day/Time:
3. Par cipant Name:
Date of Birth:
Age:
Session:
Gender:
1
2
3
Program:
May we send your receipt and program informa on by email:
Day/Time:
YES
NO
I,
, being the parent/legal guardian of the above named par cipant(s) accept full responsibility for
any and all injuries which may arise out of his/her par cipa on in programs offered by the Town of Cicero Youth Bureau, Parks &
Recrea on Department and hereby release the Town of Cicero, its agents and/or employees from any claims of any nature whatsoever
arising out of my child(ren)’s par cipa on. Consent is hereby granted to allow my child(ren) to par cipate in the above named Town of
Cicero sponsored program. Pictures and other materials which may include my child(ren) may be used by the Town of Cicero for
promo onal purposes. I agree not to drop my child(ren) off earlier than the program start me, and pick up my child(ren) by the program
end me. I will adhere to any and all implemented policies and procedures or my child(ren) will be removed from the program. No refund
will be issued. I have read, understand and agree to the above guidelines.
Parent Signature:
Date:
Refund Policy: No refunds will be given within one week BEFORE the program start date. If a refund is requested one week or more before
the program starts, a $5 administra ve fee, per person will be deducted from your refund. Convenience fees for credit card registra ons
are non‐refundable. Revised December 2012.
CREDIT CARD PAYMENTS:
Name on Card:
Billing Zip Code:
Card Number:
Exp Date:
Please Note: All credit card transac ons are assessed a 3%, plus $0.30 processing/convenience fee.
Sec Code:
Town of Cicero Youth Bureau, Parks & Recrea on, 8236 Brewerton Road, Cicero, NY 13039
h ps://cicero.recdesk.com; 315‐699‐5233; [email protected]
2015DayCampRegistrationForm
ADDITIONAL REQUIRED DAY CAMP FORMS. Registra ons NOT complete un l ALL are received with payment
Medical Authoriza on Form, Immuniza on Record, Proof of 2013‐14 Kindergarten Enrollment* (*5 year olds only)
Parent/Legal Guardian:
Address:
City:
Zip:
Home Phone:
Cell Phone:
Email Address:
Emergency Contact Name:
Emergency Contact Number:
Cicero Day Camp is licensed by the Onondaga County Health Department. The Camp is inspected a minimum of twice yearly. Inspec on
reports concerning the camp are on file at: Onondaga County Health Department, Division of Environmental Health, John H. Mulroy Civic
Center, 12th Floor, 421 Montgomery St, Syracuse, NY 13202, 315‐435‐6617
1. Par cipant Name:
Date of Birth:
Age:
Shirt Size:
Gender:
Youth:
S
M
L
Day Camp Weeks: 1
Adult:
S
M
4
5
6
2
3
4
5
6
2
3
4
5
6
Date of Birth:
Age:
Gender:
Youth:
S
M
L
Day Camp Weeks: 1
Adult:
S
M
L
3. Par cipant Name:
Date of Birth:
Age:
Shirt Size:
3
L
2. Par cipant Name:
Shirt Size:
2
Gender:
Youth:
S
M
L
Day Camp Weeks: 1
Adult:
S
M
L
Are you registering for the Extended Care Day Camp Program?
YES
NO
May we send your receipt and program informa on by email?
YES
NO
I,
, being the parent/legal guardian of the above named par cipant(s) accept full responsibility for
any and all injuries which may arise out of his/her par cipa on in programs offered by the Town of Cicero Youth Bureau, Parks &
Recrea on Department and hereby release the Town of Cicero, its agents and/or employees from any claims of any nature whatsoever
arising out of my child(ren)’s par cipa on. Consent is hereby granted to allow my child(ren) to par cipate in the above named Town of
Cicero sponsored program. Pictures and other materials which may include my child(ren) may be used by the Town of Cicero for
promo onal purposes. I agree not to drop my child(ren) off earlier than the program start me, and pick up my child(ren) by the program
end me. I will adhere to any and all implemented policies and procedures or my child(ren) will be removed from the program. No refund
will be issued. I have read, understand and agree to the above guidelines.
Parent Signature:
Date:
Refund Policy: No refunds will be given within one week BEFORE the program start date. If a refund is requested one week or more before the
program starts, a $5 administra ve fee, per person will be deducted from your refund. Convenience fees for credit card registra ons are non‐
refundable. Revised December 2012.
CREDIT CARD PAYMENTS:
Name on Card:
Billing Zip Code:
Card Number:
Exp Date:
Please Note: All credit card transac ons are assessed a 3%, plus $0.30 processing/convenience fee.
Sec Code:
2015DayCampMedicalAuthorizationForm
If your child needs medical, dental, health or hospital services, you as a parent must give permission. It is the law. What about mes when you cannot be
reached for permission? A child may be treated without parental consent when a physician demonstrates a true emergency exists. That means the doctor
determines the child needs immediate medical care and that an a empt to obtain parental consent would result in a delay which would increase the risk to
the child’s life or health.
Except in a true emergency, care may be ordinarily rendered to a child only with the consent of the parent or legal guardian. Some mes a child may need
unexpected care which is not, however, a true emergency. In such cases, making an effort to contact a parent/legal guardian for permission can delay treat‐
ment and create unnecessary anxious moments for the child.
You can prepare for the unexpected care your child might need when you are away from home. To do this, make sure babysi ers know how to reach you at
all mes. And when you know you will be hard to reach, you can give permission to other adults. They can then act for you by permi ng your child to be
treated if unexpected care is needed.
This is a legal document. With it you may appoint rela ves, friends, teachers, clergy or neighbors – anyone who is over 18 years of age – to be responsible
for your children when you are away from home. It is especially important to prepare this form for the occasions when you know it will be hard to contact
you.
Fill out this form carefully. Have your signature witnessed by an adult different from the person you are making responsible for your children. A er you
complete this form, give it to the adult(s) you have named to act on your behalf. If your child needs unexpected medical treatment, the responsible adult(s)
should present this document to the appropriate person—physician, den st or hospital representa ve.
Names of Minor
Birthdate
Iden fy allergies, medical condi ons, etc
I/We being the parent(s)/legal guardian(s) of the above named minor(s) do hereby appoint:
NAME:
Town of Cicero
ADDRESS:
NAME:
8236 Brewerton Road, Cicero, NY 13039
PHONE: 699‐5233
ADDRESS:
PHONE:
To act in my/our behalf in authorizing unexpected medical, dental, surgical care and hospitaliza on for the above named minor(s) during the period of my/
our absence.
MONTH: June
DAY:
29
YEAR:
2015
THROUGH
MONTH: August
DAY:
7
YEAR:
2015
This document shall be presented to a physician, den st or appropriate hospital representa ve at such mes as unexpected medical, dental, surgical care
or hospitaliza on may be required.
PARENT/GUARDIAN
SIGNATURE:
ADDRESS:
DATE:
SIGNATURE:
ADDRESS:
DATE:
SIGNATURE:
ADDRESS:
DATE:
SIGNATURE:
ADDRESS:
DATE:
WITNESS
HOSPITALIZATION COVERAGE FOR THE ABOVE NAMED MINOR(S)
INSURANCE COMPANY OR GOVERNMENT PROGRAM:
FAMILY PHYSICIANS
NAME & PHONE NUMBER:
NAME AND PHONE NUMBER:
ID#: