Day Camp Registration
Day Camp Registration 2000 Court Street Port Huron,MI
Camper Name______________________________________Age______Date of Birth ____ /____ /____ Address__________________________________City__________________________Zip ___________ Gender: M F Current Grade ______________ School _______________________________________ Father / Male Guardian_________________________________________ Phone _________________________ Work Phone _______________________ Email Address _____________________________________________ You may text phone number regarding Day Camp Reminders
Mother / Female Guardian_____________________________________ Phone __________________________ Work Phone _______________________ Email Address _____________________________________________ You may text phone number regarding Day Camp Reminders
In the case of an emergency, please call this person first: ________________________________________________________
Summer 2018 - Please circle the weeks that your child will be attending Day Camp: Week 1: 6/18-22
Week 2: 6/25-29
Week 3: 7/2-6
Week 4: 7/9-13
Week 5: 7/16-20
Week 6: 7/23-27
Week 7: 7/30-8/3
Week 8: 8/6-10
Week 9: 8/13-17
Week 10: 8/20-24
Hours: Day Camp hours are from 8:00am- 5:00pm. Please indicate below the times of care needed for your child. Early drop-off is available at 7:30am for a $5.00 fee/per child. Please see director at time of Registration. (Please be specific with times that care is needed, so that we can staff accordingly. Thank you!) Drop off time: ________________ Pick up time: _________________
Camper’s T-Shirt: Please circle size below. One shirt is provided; a second shirt can be purchased for an additional cost. (Child Sizes) S M L (Adult Sizes) S M L XL □ I would like to order an extra T-shirt for an extra $10.00
Emergency Contacts: In the event of an emergency and a parent/guardian cannot be contacted, please list any other emergency contact that you would ask us to contact. My child may be released only to his/her legal guardians or the following Emergency Contacts: ___________________________________
___________________________
_____________________
_________________
Name
Relationship
Home Phone
Work Phone
___________________________________
___________________________
_____________________
_________________
Name
Relationship
Home Phone
Work Phone
Child Information (Please fill out completely providing all current information.) Medical Insurance Carrier & Number _____________________________________________________________________________________________________ List any recent illnesses / or medical problems we should be aware of: _____________________________________________________________________________________________________ List any allergies that your child has (include medication allergies): _____________________________________________________________________________________________________ Is your child on any medications currently? ___________ If yes, what type? _______________________________________ Are there any special needs, behavioral considerations, limitations or adaptations needed to assist in participation of camp life & activities? _____________________________________________________________________________________________________
Swimming Ability: (Of child on this registration form. Check only one.)
□Non-swimmer □ Beginner (capable of swimming for several minutes) □Moderate (capable of swimming several pool lengths and in deep water) □Advanced Does he or she have your permission to swim? Yes□ No□ Additional Notes: ____________________________________________________________________________________
Does he or she need to wear a life jacket (provided from home) on swimming days? Yes□
No □
Consent and Release Information: My signature below acknowledges agreement to the following: Activity Release: The above named child has my permission to attend the Summer Day Camp at The Salvation Army Port Huron. He/she is free to participate in all the activities listed in the Day Camp Handbook as well as the off-site field trips. It is agreed that I do not hold The Salvation Army responsible for negligence on the part of my child during any aspect of this program. Photo Release: In the event that The Salvation Army would wish to use a photo of my child in its publicity, my permission is granted. This includes both print and electronic media. Health Release: In the event that a parent or emergency contact cannot be reached, The Salvation Army’s Day Camp Leaders have my permission to secure emergency medical and / or surgical treatment for the above named child. Registration Fees & Deposits: Registration forms must have a non-refundable $35 registration fee, along with a payment covering two weeks of care. The remainder of the fee is due according to the fee schedule. There are NO REFUNDS after Day Camp begins. In signing below, I agree that all of the information I have given is accurate. False information will result in the termination of my child’s membership in the program. If any changes in the information provided should occur, I will immediately notify the Community Center Office.
Parent’s Signature ______________________________________________ Date: _____________________ (Must be signed for admission.) Do you have a Church you currently attend? Yes□ No□ Are you interested in more information about The Salvation Army as a church? Yes, please! □ How did you hear about Day Camp? Flyer□ E-mail□ Word of Mouth□ Returning□ Other: ____________________________________
No, thank you. □
Field Trip Permission Slip 2018 Day Camp I, __________________________________________, understand that while my child is participating in The Salvation Army Port Huron Summer Day Camp from June 18-August 24, 2018 that my child may be traveling off the premises of 2000 Court St. Port Huron, MI 48060 to participate in various field trips. I hereby give permission for my child/ren: ________________________________________ to participate in the following field trips: Please initial all: June 18, 2018:
Pump It Up (Shelby Township, MI)
________
June 21, 2018:
Pine River Nature Center (Goodells, MI)
________
June 25, 2018:
Greenfield Village (Dearborn, MI)
________
June 28, 2018:
MI Science Center (Detroit, MI)
________
July 3, 2018:
Krafft 8 (Port Huron, MI)
________
July 5, 2018:
Ford Field Tour (Detroit, MI)
________
July 9, 2018:
Metro Beach Pool (Harrison Township, MI)
________
July 12, 2018:
Detroit Institute of Art (Detroit, MI)
________
July 17, 2018:
4H Fair (Goodells, MI)
________
July 19, 2018:
The Parade Company (Detroit, MI)
________
July 23, 2018:
Spencer Beach (Rochester Hills, MI)
________
July 26, 2018:
Comerica Park Tour (Detroit, MI)
________
July 31, 2018:
Field Day @ Echo Grove (Leonard, MI)
________
August 2, 2018:
The Henry Ford (Dearborn, MI)
________
August 6, 2018:
Jeepers (Sterling Heights, MI)
________
August 9, 2018:
Longway Planetarium (Flint, MI)
________
August 13, 2018:
PH Lanes (Port Huron, MI)
________
August 15, 2018:
All American Flames Gymnastix (Port Huron, MI)
________
August 20, 2018:
Spencer Beach (Rochester Hills, MI)
________
August 23, 2018:
Seven Ponds Nature Center (Dryden, MI)
________
August 24, 2018:
Jimmy’s Frozen Custard (Port Huron, MI)
________
June: 20, 27 July: 6, 11, 18, 25 Aug: 1, 8, 22 Local Parks: Roosevelt, Palmer (Port Huron), Marysville Park (Marysville), Imagination Station (St.Clair) ________ June: 20, 22, 27, 29 July: 11, 13, 18, 20, 25, 27 Aug: 1, 3, 8, 10, 14
Court Street Pool (Port Huron, MI) ________
Several occasions:
Roosevelt School Playground & Port Huron High School Fields
________
Alternate Field Trips:
Movies (locally), Local Parks, or repeat of another indoor trip.
________
Functions and Activities It is my understanding that participating in the programs, recreational and other activities of The Salvation Army is a privilege. Prior to my participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, and physical injury due to transportation-related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware. Release of Liability By signing this Permission/Waiver Form, I expressly warrant that the child named on the front is capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child or me participating in the activities, whether such risks are known or unknown to me at this time. I further release The Salvation Army and its staff, volunteers, and agents from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation), any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of the child’s or my family or estate, heirs, representatives, or assigns may have against The Salvation Army or its staff, volunteers, or agents. I further agree to indemnify and hold harmless The Salvation Army and its staff volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my child during such activities. I represent that I am the parent/guardian of________________________________________________________, who is under 18 years of age. I have read the above Field Trip Permission Slip Form and am fully familiar with the contents thereof. I give permission for the child named above to participate in the activities of The Salvation Army, including any special events/activities described above. In consideration for allowing the participation of the child in the activities of The Salvation Army, I hereby consent to the Field Trip Permission Slip Form, including the Release of Liability above, on behalf of the child, and agree that this Field Trip Permission Slip Form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns.
____________________________________________________________ Signature of Parent or Legal Guardian
______________________________________________________________ Print Name of Parent or Legal Guardian
______________________ Date
Camper Name______________________________________Age______Date of Birth ____ /____ /____ Address__________________________________City__________________________Zip ___________ Gender: M F Current Grade ______________ School _______________________________________ Father / Male Guardian_________________________________________ Phone _________________________ Work Phone _______________________ Email Address _____________________________________________ You may text phone number regarding Day Camp Reminders
Mother / Female Guardian_____________________________________ Phone __________________________ Work Phone _______________________ Email Address _____________________________________________ You may text phone number regarding Day Camp Reminders
In the case of an emergency, please call this person first: ________________________________________________________
Summer 2018 - Please circle the weeks that your child will be attending Day Camp: Week 1: 6/18-22
Week 2: 6/25-29
Week 3: 7/2-6
Week 4: 7/9-13
Week 5: 7/16-20
Week 6: 7/23-27
Week 7: 7/30-8/3
Week 8: 8/6-10
Week 9: 8/13-17
Week 10: 8/20-24
Hours: Day Camp hours are from 8:00am- 5:00pm. Please indicate below the times of care needed for your child. Early drop-off is available at 7:30am for a $5.00 fee/per child. Please see director at time of Registration. (Please be specific with times that care is needed, so that we can staff accordingly. Thank you!) Drop off time: ________________ Pick up time: _________________
Camper’s T-Shirt: Please circle size below. One shirt is provided; a second shirt can be purchased for an additional cost. (Child Sizes) S M L (Adult Sizes) S M L XL □ I would like to order an extra T-shirt for an extra $10.00
Emergency Contacts: In the event of an emergency and a parent/guardian cannot be contacted, please list any other emergency contact that you would ask us to contact. My child may be released only to his/her legal guardians or the following Emergency Contacts: ___________________________________
___________________________
_____________________
_________________
Name
Relationship
Home Phone
Work Phone
___________________________________
___________________________
_____________________
_________________
Name
Relationship
Home Phone
Work Phone
Child Information (Please fill out completely providing all current information.) Medical Insurance Carrier & Number _____________________________________________________________________________________________________ List any recent illnesses / or medical problems we should be aware of: _____________________________________________________________________________________________________ List any allergies that your child has (include medication allergies): _____________________________________________________________________________________________________ Is your child on any medications currently? ___________ If yes, what type? _______________________________________ Are there any special needs, behavioral considerations, limitations or adaptations needed to assist in participation of camp life & activities? _____________________________________________________________________________________________________
Swimming Ability: (Of child on this registration form. Check only one.)
□Non-swimmer □ Beginner (capable of swimming for several minutes) □Moderate (capable of swimming several pool lengths and in deep water) □Advanced Does he or she have your permission to swim? Yes□ No□ Additional Notes: ____________________________________________________________________________________
Does he or she need to wear a life jacket (provided from home) on swimming days? Yes□
No □
Consent and Release Information: My signature below acknowledges agreement to the following: Activity Release: The above named child has my permission to attend the Summer Day Camp at The Salvation Army Port Huron. He/she is free to participate in all the activities listed in the Day Camp Handbook as well as the off-site field trips. It is agreed that I do not hold The Salvation Army responsible for negligence on the part of my child during any aspect of this program. Photo Release: In the event that The Salvation Army would wish to use a photo of my child in its publicity, my permission is granted. This includes both print and electronic media. Health Release: In the event that a parent or emergency contact cannot be reached, The Salvation Army’s Day Camp Leaders have my permission to secure emergency medical and / or surgical treatment for the above named child. Registration Fees & Deposits: Registration forms must have a non-refundable $35 registration fee, along with a payment covering two weeks of care. The remainder of the fee is due according to the fee schedule. There are NO REFUNDS after Day Camp begins. In signing below, I agree that all of the information I have given is accurate. False information will result in the termination of my child’s membership in the program. If any changes in the information provided should occur, I will immediately notify the Community Center Office.
Parent’s Signature ______________________________________________ Date: _____________________ (Must be signed for admission.) Do you have a Church you currently attend? Yes□ No□ Are you interested in more information about The Salvation Army as a church? Yes, please! □ How did you hear about Day Camp? Flyer□ E-mail□ Word of Mouth□ Returning□ Other: ____________________________________
No, thank you. □
Field Trip Permission Slip 2018 Day Camp I, __________________________________________, understand that while my child is participating in The Salvation Army Port Huron Summer Day Camp from June 18-August 24, 2018 that my child may be traveling off the premises of 2000 Court St. Port Huron, MI 48060 to participate in various field trips. I hereby give permission for my child/ren: ________________________________________ to participate in the following field trips: Please initial all: June 18, 2018:
Pump It Up (Shelby Township, MI)
________
June 21, 2018:
Pine River Nature Center (Goodells, MI)
________
June 25, 2018:
Greenfield Village (Dearborn, MI)
________
June 28, 2018:
MI Science Center (Detroit, MI)
________
July 3, 2018:
Krafft 8 (Port Huron, MI)
________
July 5, 2018:
Ford Field Tour (Detroit, MI)
________
July 9, 2018:
Metro Beach Pool (Harrison Township, MI)
________
July 12, 2018:
Detroit Institute of Art (Detroit, MI)
________
July 17, 2018:
4H Fair (Goodells, MI)
________
July 19, 2018:
The Parade Company (Detroit, MI)
________
July 23, 2018:
Spencer Beach (Rochester Hills, MI)
________
July 26, 2018:
Comerica Park Tour (Detroit, MI)
________
July 31, 2018:
Field Day @ Echo Grove (Leonard, MI)
________
August 2, 2018:
The Henry Ford (Dearborn, MI)
________
August 6, 2018:
Jeepers (Sterling Heights, MI)
________
August 9, 2018:
Longway Planetarium (Flint, MI)
________
August 13, 2018:
PH Lanes (Port Huron, MI)
________
August 15, 2018:
All American Flames Gymnastix (Port Huron, MI)
________
August 20, 2018:
Spencer Beach (Rochester Hills, MI)
________
August 23, 2018:
Seven Ponds Nature Center (Dryden, MI)
________
August 24, 2018:
Jimmy’s Frozen Custard (Port Huron, MI)
________
June: 20, 27 July: 6, 11, 18, 25 Aug: 1, 8, 22 Local Parks: Roosevelt, Palmer (Port Huron), Marysville Park (Marysville), Imagination Station (St.Clair) ________ June: 20, 22, 27, 29 July: 11, 13, 18, 20, 25, 27 Aug: 1, 3, 8, 10, 14
Court Street Pool (Port Huron, MI) ________
Several occasions:
Roosevelt School Playground & Port Huron High School Fields
________
Alternate Field Trips:
Movies (locally), Local Parks, or repeat of another indoor trip.
________
Functions and Activities It is my understanding that participating in the programs, recreational and other activities of The Salvation Army is a privilege. Prior to my participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, and physical injury due to transportation-related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware. Release of Liability By signing this Permission/Waiver Form, I expressly warrant that the child named on the front is capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child or me participating in the activities, whether such risks are known or unknown to me at this time. I further release The Salvation Army and its staff, volunteers, and agents from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation), any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of the child’s or my family or estate, heirs, representatives, or assigns may have against The Salvation Army or its staff, volunteers, or agents. I further agree to indemnify and hold harmless The Salvation Army and its staff volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my child during such activities. I represent that I am the parent/guardian of________________________________________________________, who is under 18 years of age. I have read the above Field Trip Permission Slip Form and am fully familiar with the contents thereof. I give permission for the child named above to participate in the activities of The Salvation Army, including any special events/activities described above. In consideration for allowing the participation of the child in the activities of The Salvation Army, I hereby consent to the Field Trip Permission Slip Form, including the Release of Liability above, on behalf of the child, and agree that this Field Trip Permission Slip Form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns.
____________________________________________________________ Signature of Parent or Legal Guardian
______________________________________________________________ Print Name of Parent or Legal Guardian
______________________ Date
