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The Salvation Army Ray & Joan Kroc Corps Community Center Summer with RJ Day Camp Camper Enrollment Form- 2015 Basic Camp information: Camp dates are from 7/6/15-9/4/15; Camp hours are from 9am- 5pm; extended say is available at an additional fee ($25). There fee for camp is $150 (members) and $185 (non- members) weekly, and all snacks and meals are provided free of charge. Students must currently be between 6-12 years old to participate. Student must have their own transportation to and from the camp on a daily basis. Parents will be required to pick students up for violation of misconduct outlined in the parent manual. A detailed schedule of activities will be provided upon first day of camp, including meal information. Contact Nakennia President for any additional questions: Nakennia.president@use.salvationarmy.org; (617)318-6965. Students will be accepted to the camp in a first come, first serve basis as there are limited spots available. The student will be place on the camp roster upon submission of completed application and the first week s payment has been processed. Campers are not guaranteed a slot in future weeks until payment has been made. The process is different for campers entering with a financial voucher. Child s Name: Home Phone: Home Address: zip code: Date of Birth: Indentifying Marks: Age as of 7/6/2015: Primary Language: Payments Method (Self Pay, Voucher, Etc.): Academic Concerns (IEP, etc.): Behavioral Concerns (ADHD, other behavioral disorders): Parent/Guardian Information Parent/Guardian Name: Parent/Guardian Name: Relationship to child: Relationship to child: Address: Address: Home Phone: Mobile Phone: Place of Employment: Business Phone: Hours at work: Home Phone: Mobile Phone: Place of Employment: Business Phone: Hours at work: Enrollment Weeks Selected (please circle weeks your child will be attending the day camp): July 6-July 10 July 13-July 17 July 20-July 24 July 27- July 31 August 3- August 7 August 10- August 14 August 17-August 21 August 24-August 28 2 August 31-September 4 Please note circling the session without completing the payment for each session does not guarantee enrollment in the session.
The Salvation Army Ray & Joan Kroc Corps Community Center Summer with RJ Day Camp Camper Entry/Exit Information Form 2015 Child s Name: Child will arrive at the program by: Parent/Guardian drop-off Bus Service Other **Please note: All Campers must be signed in/out by an adult. Campers are not allowed to sign themselves in** I give permission to the following people to receive my child at the end of the day. (If no one is authorized, please indicate below by writing NO ONE ): Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: Emergency Contacts (in order to be contacted): Name: Relationship: Address: Phone: Do you give permission for your child to be released to this person?: Name: Relationship: Address: Phone: Do you give permission for your child to be released to this person? 3
PARENTAL PERMISSION AND MEDIA AUTHORIZATION FORM Participant Name: Birth date: Permission to Participate I give permission for my child (named above) to attend the events, field trips, and service projects associated with The Salvation Army. I further give permission for my child to be transported to and from events by hired and/or volunteer drivers authorized by The Salvation Army Media Authorization I hereby irrevocably grant The Salvation Army, its successors and assigns, its agents and those by whom it is commissioned, the absolute, unrestricted and unlimited license, right, permission, and consent to use and reuse, disseminate, copyright, print, reproduce, publish and republish, for any and all trade purposes or commercial or other advertising or public purposes, and in any and all advertising, publicity, display, publication or media, my name, signature and likeness, and any portraits, pictures, photographic prints or other representations of me, or in which I may appear, or any reproductions or sketches thereof or parts thereof, photographic or otherwise, with such additions, deletions, alterations or changes therein as you in your discretion may take, either separately or together with my name or a fictitious name, or the name of another person, with or without any statements or testimonials made by me, or authorized by me which you may, in your discretion, prepare for use in connection therewith. I warrant that I have not limited or restricted the use of my name or photograph to use of any organization or person. I hereby grant unrestricted use of audio tracks or texts by The Salvation Army for such purposes as The Salvation Army may deem appropriate. Authorization Relating to a Minor or Individual under Local Guardianship I hereby certify that I am the (parent) (legal guardian) of a minor, child or dependent, and have executed this release on (his)/ (her) behalf. Child s name (Print Name) (Sign Name) (Address) (Date) 4
SUMMER HEALTH FORM This form must be completed and signed by the participant s legal guardian. The information we ask you to provide is necessary in the event your child needs medical treatment while camp is in session. This form will be returned to you if it is incomplete. Please type or print in black ink. PARTICIPANT (Camper) INFORMATION Participant s Name Permanent Address Date of Birth Sex City/State/Zip Home Phone MEDICAL EMERGENCY CONTACT INFORMATION Person to contact first: Backup contact (relative or friend): Name _ Name Relation Relation Daytime Phone Daytime Phone Evening Phone Evening Phone INSURANCE POLICY INFORMATION The above- named child is covered by health insurance: Yes No If yes, provide the following information which is required by the Salvation Army Kroc Center to expedite treatment and to facilitate the billing process. Policy Holder s (P.H.) Name P.H. s Date of Birth Address Relation City/State/Zip Occupation P.H. s Employer Employer s Address Insurance Company Insurance Company s Address Policy # Plan # 5
MEDICAL TREATMENT CONSENT I, the legal guardian of the above- named camper, authorize the Summer with R.J. Summer Program staff to seek medical treatment for the camper as they see necessary at the closest medical facility. I consent to any x- ray, anesthetic, medical or surgical diagnosis or treatment and hospital care subsequently deemed necessary by a licensed health care provider during the participant s session. I understand that this authorization is given in advance of any specific diagnosis, treatment or hospital care, and that it is given to provide the program staff authority to seek medical treatment, and to provide a licensed health care provider the authority to administer this treatment as s/he judges necessary to the above- named child. I accept responsibility for payment of all services rendered; I authorize any medical facility which renders services to release medical information necessary for the processing of insurance claims; and I authorize the payment of insurance claims directly to the medical facility. I understand that whenever possible, the Program staff will make a good faith effort to contact me or the above- named person(s) before seeking treatment. If this is not possible, I understand that the Program staff will notify me or my designee as soon a possible of any and all diagnoses and treatments. Legal Guardian s Signature Print Name Date 6
Directions: Completion of this form by a parent or guardian is required before a student can participate. Please answer all questions. Incomplete forms will be returned to you for the missing information. Please type or print in black ink. Attach any specific recommendations from your physician to this form. DOES THE PARTICIPANT CURRENTLY HAVE ANY OF THE FOLLOWING? (if yes, please describe) Drug allergies: Food allergies: Allergies to insect bites: Special dietary needs: Asthma: Frequent headaches: Dizziness or seizures: LIST: Other health problems: Limitations of Activities: Medications the camper is currently taking: (Please note: Our staff cannot administer any medications, prescription or non- prescription to campers. This includes over- the- counter medicines like Advil or Tylenol for minor headaches or pains. If the camper will need to take medications while attending our program, s/he must bring the medication to camp and assume responsibility for taking it as needed or indicated.) Will your son/daughter require any specific treatment for a medical/emotional condition while participating in our program? If yes, please explain. yes no 7
MEDICAL HISTORY IMMUNIZATION DATES: Measles Mumps Rubella Date of last medical check- up: Hospitalizations in the past 5 years: Describe OR MMR Last Tetanus (DPT, TT or TD) Polio Series completes PHYSICIAN S INFORMATION Please PRINT the following information: Physician s Name: Address: City/State/Zip Telephone Please include your child s most recent physical form (must be within a year) with immunization records. *A physical must be submitted before 7/3/2015 (or before your child s start date if you plan to have your child start in a later session* 8