Summer Day Camp Registration 2018
Summer Day Camp Registration 2018 June 11-August 10, 2018: 9am-4pm Ages 5-12 For Provider Date of Admission Use Only:
______________
Date of Discharge ______________
CHILD INFORMATION Child: ______________________________________Age: ________ DOB: ___________ Gender (Circle one): M/F School: ___________________________ Grade in Fall: _______ Home Address: ________________________________________City: _________________________Zip: _______
Physician/Health Clinic:_______________________________________
Phone:________________________
Medication: __________________________________________________ Times Taken: ________________________________________________ Allergies/Special Needs/Special Instructions: _____________________________________________________________
Swim Level (Circle) one) :
Beginner
Intermediate
Advanced
T-SHIRT SIZE (circle one) :
Youth Small (6/8)
Youth Medium (10/12)
Youth Large (14/16)
Adult Small
Adult Medium Adult Large
Please make sure you order the proper size. When in doubt, order a larger size! Parents will be charged for any additional shirts that need to be ordered due to an error in size.
PARENT/ GUARDIAN INFORMATION
(Also used as Emergency Contact and Release of child)
Mother/Guardian: ________________________________________
Father/Guardien: ________________________________________
Phone:
Phone:
(C/H)_______________________________
(C/H)_______________________________
(W) ________________________________
(W) ________________________________
Home Address: ________________________________________
Home Address: ________________________________________
City: _________________________Zip: _______
City: _________________________Zip: _______
Employer: _______________________________
Employer: _______________________________
Email: __________________________________
Email: __________________________________
RELEASE INFORMATION
____Activity Release: The above named child has my permission to attend the Summer Programs at The SAL, which is sponsored by The Salvation Army in Grand Rapids, MI. They are free to participate in all the outlined activities, as well as, all of the offsite activities which are provided through day camp each week. It is agreed that I do not hold The Salvation Army responsible for negligence on the part of my child during any aspect of the summer program. I understand that my child is protected by The Salvation Army’s insurance coverage, provided the injury occurs between the regular hours of the program and that The Salvation Army or an outside organization is liable for the negligence. ____Photo Release: In the event that The SAL would wish to use a photo of my child in publications & websites, my permission is granted. ____ Emergency Medical Care: In the event that a parent or the emergency contact cannot be reached, The SAL Community Center has my permission to secure emergency medical treatment for the above named child. NON-EMERGENCY treatment is not included in this release. ____ Prescription Medication: In the event that prescription medication is to be administered, the SAL Community Center may administer medication as specified in written instructions.
Initial the above to which you agree and sign here Parent Signature: ____________________________________________ Date: _____________ CAMPER AGREEMENT I promise to do my best to make good choices while I am a camper at The SAL. I will obey the rules and respect all other campers and leaders. I understand that if I break the rules or show disrespect to others, my participation in the day camp could be terminated. I sign this agreement on my honor. Camper Signature:__________________________________________________________
In Case of an Emergency, if parent cannot be reached, please contact: (Also used as Release of Child) 1)Name: ____________________________________________________ Phone: _____________________________________________________ 2)Name: ____________________________________________________ Phone: _____________________________________________________ 3)Name: ____________________________________________________ Phone: _____________________________________________________
Dates
Weekly Theme
Field Trip
June 11-15
Super Heroes
Fire Station
June 18-22
Sports
Bowling
June 25-29
Great Outdoors
Hemlock Groves
July 9-13
Safari
Boulder Ridge Animal Park
July 16-20
Earth & Sky
Recycling Plant & Planetarium
July 23-27
Science
Children’s Museum
July 30-August 3
Farming & Food
Urban Roots & Fulton Farmer’s Market
August 6-10
Water
Millennium Park Beach
Cost: $75/week Extended hour care is available for an additional fee as listed below. Fee includes weekly field trip, t-shirt, all snacks and lunches. In the event that a trip must be cancelled, it will be replaced with a trip containing similar content. AM Extended Hours (8am-9am) $15 per week due at the beginning of each week PM Extended Hours (4pm-6pm) $25 per week due at the beginning of each week Note: All registration forms must have payment in full due the Friday before the first day of camp in order to be accepted for camp. Families registering for more than one week may pay on a weekly basis the Friday before the start of the next camp. Children will not be admitted to camp without payment prior to the first day of camp.
PM Extended Hours
PM Extended Hours PM Extended Hours
AM Extended Hours
AM Extended Hours AM Extended Hours
July 23-27
July 30-August 3
August 6-10
TOTAL
FOR OFFICE USE ONLY Registration Paid Date:______________ Amnt. Pd._____________ Receipt #_________________ Check #________________ Balance Due________________ Final Payment Date: ________________
PM Extended Hours
AM Extended Hours
July 16-20
AMOUNT
PM Extended Hours
AM Extended Hours
July 9-13
Fee
PM Extended Hours
AM Extended Hours
June 25-29
Registration
PM Extended Hours
AM Extended Hours
June 18-22
Weeks Attending
PM Extended Hours
AM Extended Hours
June 11-15
______________
Date of Discharge ______________
CHILD INFORMATION Child: ______________________________________Age: ________ DOB: ___________ Gender (Circle one): M/F School: ___________________________ Grade in Fall: _______ Home Address: ________________________________________City: _________________________Zip: _______
Physician/Health Clinic:_______________________________________
Phone:________________________
Medication: __________________________________________________ Times Taken: ________________________________________________ Allergies/Special Needs/Special Instructions: _____________________________________________________________
Swim Level (Circle) one) :
Beginner
Intermediate
Advanced
T-SHIRT SIZE (circle one) :
Youth Small (6/8)
Youth Medium (10/12)
Youth Large (14/16)
Adult Small
Adult Medium Adult Large
Please make sure you order the proper size. When in doubt, order a larger size! Parents will be charged for any additional shirts that need to be ordered due to an error in size.
PARENT/ GUARDIAN INFORMATION
(Also used as Emergency Contact and Release of child)
Mother/Guardian: ________________________________________
Father/Guardien: ________________________________________
Phone:
Phone:
(C/H)_______________________________
(C/H)_______________________________
(W) ________________________________
(W) ________________________________
Home Address: ________________________________________
Home Address: ________________________________________
City: _________________________Zip: _______
City: _________________________Zip: _______
Employer: _______________________________
Employer: _______________________________
Email: __________________________________
Email: __________________________________
RELEASE INFORMATION
____Activity Release: The above named child has my permission to attend the Summer Programs at The SAL, which is sponsored by The Salvation Army in Grand Rapids, MI. They are free to participate in all the outlined activities, as well as, all of the offsite activities which are provided through day camp each week. It is agreed that I do not hold The Salvation Army responsible for negligence on the part of my child during any aspect of the summer program. I understand that my child is protected by The Salvation Army’s insurance coverage, provided the injury occurs between the regular hours of the program and that The Salvation Army or an outside organization is liable for the negligence. ____Photo Release: In the event that The SAL would wish to use a photo of my child in publications & websites, my permission is granted. ____ Emergency Medical Care: In the event that a parent or the emergency contact cannot be reached, The SAL Community Center has my permission to secure emergency medical treatment for the above named child. NON-EMERGENCY treatment is not included in this release. ____ Prescription Medication: In the event that prescription medication is to be administered, the SAL Community Center may administer medication as specified in written instructions.
Initial the above to which you agree and sign here Parent Signature: ____________________________________________ Date: _____________ CAMPER AGREEMENT I promise to do my best to make good choices while I am a camper at The SAL. I will obey the rules and respect all other campers and leaders. I understand that if I break the rules or show disrespect to others, my participation in the day camp could be terminated. I sign this agreement on my honor. Camper Signature:__________________________________________________________
In Case of an Emergency, if parent cannot be reached, please contact: (Also used as Release of Child) 1)Name: ____________________________________________________ Phone: _____________________________________________________ 2)Name: ____________________________________________________ Phone: _____________________________________________________ 3)Name: ____________________________________________________ Phone: _____________________________________________________
Dates
Weekly Theme
Field Trip
June 11-15
Super Heroes
Fire Station
June 18-22
Sports
Bowling
June 25-29
Great Outdoors
Hemlock Groves
July 9-13
Safari
Boulder Ridge Animal Park
July 16-20
Earth & Sky
Recycling Plant & Planetarium
July 23-27
Science
Children’s Museum
July 30-August 3
Farming & Food
Urban Roots & Fulton Farmer’s Market
August 6-10
Water
Millennium Park Beach
Cost: $75/week Extended hour care is available for an additional fee as listed below. Fee includes weekly field trip, t-shirt, all snacks and lunches. In the event that a trip must be cancelled, it will be replaced with a trip containing similar content. AM Extended Hours (8am-9am) $15 per week due at the beginning of each week PM Extended Hours (4pm-6pm) $25 per week due at the beginning of each week Note: All registration forms must have payment in full due the Friday before the first day of camp in order to be accepted for camp. Families registering for more than one week may pay on a weekly basis the Friday before the start of the next camp. Children will not be admitted to camp without payment prior to the first day of camp.
PM Extended Hours
PM Extended Hours PM Extended Hours
AM Extended Hours
AM Extended Hours AM Extended Hours
July 23-27
July 30-August 3
August 6-10
TOTAL
FOR OFFICE USE ONLY Registration Paid Date:______________ Amnt. Pd._____________ Receipt #_________________ Check #________________ Balance Due________________ Final Payment Date: ________________
PM Extended Hours
AM Extended Hours
July 16-20
AMOUNT
PM Extended Hours
AM Extended Hours
July 9-13
Fee
PM Extended Hours
AM Extended Hours
June 25-29
Registration
PM Extended Hours
AM Extended Hours
June 18-22
Weeks Attending
PM Extended Hours
AM Extended Hours
June 11-15
