Watertown Recreation Department

149 Main Street ● Watertown, MA 02472

Phone: 617-972-6494 ● Fax: 617-926-6129
recreation@watertown-ma.gov ● www.recreation.watertown-ma.gov

PEQUOSSETTE SUMMER RECREATION PROGRAM

APPROVED FOR PICKUP
We understand that primary guardians occasionally will need someone other than themselves to pick up their child from
camp. To better serve your family and to keep the safety of your child a priority, please provide us with the information for
three individuals, who are not the primary guardians, whom you give permission to pick up your child. When one of these
individuals comes to pick up your child, we will check his/her photo ID and that he or she is approved for pickup before
allowing your child to leave. If an individual is not approved for pickup, or if permission has not been communicated with
us either through a note, e-mail or phone call, you will be contacted via phone for your permission.

Child’s Name: _________________________________________ Age ______ Child’s Grade in Fall ’18: _____________

Parent/Guardian #1 Name (Print)_____________________________________ Telephone: _______________________

Parent/Guardian #2 Name (Print)_____________________________________ Telephone: _______________________

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Approved for Pickup #1

Name ___________________________________________________________________________________________

Relationship to Camper _____________________________________________________________________________

Phone Number ____________________________________________________________________________________

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Approved for Pickup #2

Name ___________________________________________________________________________________________

Relationship to Camper _____________________________________________________________________________

Phone Number ____________________________________________________________________________________

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Approved for Pickup #3

Name ___________________________________________________________________________________________

Relationship to Camper _____________________________________________________________________________

Phone Number ____________________________________________________________________________________

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PARENT/GUARDIAN SIGNATURE

Parent’s/Guardian’s Name (Print) _____________________________________________________________________

Parent’s/Guardian’s Signature _______________________________________________________________________