Kroc Sports Camp Form Registration Form

Kroc Sports Camp Form
Registration Form
(Please complete one per child)
Camper’s Name: ______________________________________________________
Date of Birth: ____________________________________
Parent (s) Name (s): _________________________________________ Camper lives with (custodial parent):_______________________________
Home Ph #: ________________________ Work Ph #: _____________________ Cell Ph #: (a) __________________ (b) _______________
Address: ________________________________________________ City: _________________ State: _______
Zip: ____________________
Parent Email: _________________________________________________________ Camper’s School: ____________________________________
How did you hear about us?
□ Kroc Center Flyer □ Newspaper Ad □ Magazine Ad
□ Radio Ad
□ Friend
□ School
□ Other_____________________
□ Kroc Center Member
□ Internet
Kroc
Camp
Volleyball RJ
Skills
Camp
Kroc Sport Camps
□
Camps are half days from
July 9am-12pm
9 – 13, 2012
Session Dates
□June 25-27 Volleyball ($100)
th
Week 1
Week 2
Week 3
Week 4
□June 11-14
□ June 4 – 8, 2012
□9:00am-3:00pm
June 11 – 15, 2012
A 3 day Camp from
Third day of camp
a half
□ isJune
18 day.
– 22, 2012
□ June 25 – June 29, 2012
th
□June 18-21 Basketball ($75)
Capacity
□ July 16 – 20,
2012
Baseball-40
□ July 23 Basketball-20
– 27, 2012
Football-40
□ July 30 – August
2012
st
Baseball ($75)
Week 6
□JulyWeek
9-127 Football ($75)
th
Week 8
Contact the Kroc Athletic Department at 228-207-1218 for more information.
Camper Information:
□ K K □ 1 □ 2 □ 33 □44 □ 55 □66 □77 □ 88 □99 □1010
□Kroc Center Youth Membership
□Kroc Center Family Membership
□ Small
□ Medium
□ Large
□ x-Large
Youth:
My child has completed: (Check one) Grade:
My child has a:
Child’s Shirt Size:
NOTE: Space is limited; registration will be accepted on first-come, first-served basis. No refunds are given unless the camp is cancelled by the
Kroc Center.
Member: $65.00 per week
Non Members: $75.00 per week
□
□Second Child:
□
□Second Child:
$60.00 per week
□
$70.00 per week
Third Child: $55.00per week
Payment Information:
I PREFER THE FOLLOWING PAYMENT OPTION:
Will pay with credit card (please fill out information below)
□
□
Visa
MasterCard
Please charge my:
Name as it appears on the card: ________________________________
Card #: ____________________________________________________
Signature: __________________________________________________
□Discover
Account#:______________________________
Billing Address: _________________________________________
Expiration Date: _________________________________________
Today’s Date: ___________________________________________
Will pay with EFT (please fill out the information below)
By signing, I give The Salvation Army Kroc Center authorization to deduct weekly payments up to for 8 weeks for summer day camp directly from the listed bank
account at my financial institution. I understand that Pay
all debits
from mymade
bank account
be Kroc
conducted
every Friday prior to the week I am enrolling in summer day
w/check
out towill
the
Center.
camp. This authorization is to remain in full force and effect until the Salvation Army Kroc Center has received written notification from me of its termination or
balance is paid in full. Any debt request in process at the time we receive the notice of termination will be completed.
Please provide voided check with this application (if applicable).
Electronic Funds Transfer (EFT) Information
Name: (of bank account holder) ___________________________________ Bank Name: _____________________________________________
Account #: _____________________________ Transit/ABA# (first 9 digits on check: _________________________________________________
Signature: _________________________________________ Date: __________________________________
Consent for Pictures/Videos:
I agree to allow The Salvation Army Kroc Center to use and publish for advertising any pictures or videos where the Camper (the minor child for
□ YES
whom I am signing) appear. (Pictures will only be used to promote the Kroc Center.)
□ NO
Health History Form:
(Please complete one per child)
_______________________________________________
The information provided below will assist our staff in providing
the best care for your child. Check if applicable or allergic:
Name of Minor/Camper: Please PRINT
□ Diabetes
□ Epilepsy
□ Insect Stings
Emergency Contact & Pick Up Authorization
□
□
□
Asthma
Carries Inhaler
□ Carries Epi-Pen
□ Behavioral Challenges
(We require 2 emergency contacts other than the parents)
Name: ________________________________________________
Penicillin
Other: _____________________________________________________________
___________________________________________________________________
Relationship: __________________________________________
Phone #: _______________________________________
Dietary restrictions: _________________________________________________
___________________________________________________________________
Restrictions on physical activity: _______________________________________
___________________________________________________________________
___________________________________________________________________
Name & purpose of any medication: _____________________________________
___________________________________________________________________
___________________________________________________________________
Please list anything else that may affect your child’s experience at
camp. (i.e.: moving to new home, divorce):
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Name: ________________________________________________
Relationship: __________________________________________
Phone #: _______________________________________
People NOT AUTHORIZED to pick up my camper:
Name: __________________________________________
Name: __________________________________________
Family Doctor: ___________________________________
Doctor’s Phone: (_____) ____________________________
Doctor’s Address: _________________________________
________________________________________________
Liability Waiver:
Parent/Legal Guardian is required to sign authorization and waiver below to acknowledge understanding and agreement of the content.
Upon condition of the participation of my child in The Salvation Army Kroc Center Sport Day Camp program at 575 Division Street, Biloxi. MS, I agree
to assume the risk for any injuries, including death, that may be sustained by my child/children in connection with the use of said premises. Further, I
agree on behalf of myself and my child/children, to indemnify, hold harmless, assume liability for and defend The Salvation Army Kroc Center, its
trustee, officers, employees, volunteers, members and agents from all costs and expenses including, but not limited to attorney’s fees, reasonable
investigative and discovery costs, court costs and any other sums which The Salvation Army Kroc Center, its trustees, officers, members, employees,
volunteers, members and agents may pay or become obligated to pay for injury, including death, to persons or damage to property resulting from our
use of said premises or from our actions or omissions and arising from any cause, including vehicles, except for matters caused by the negligence or
willful misconduct of The Salvation Army Kroc Center or its trustees, officers, employees, volunteers, members and agents while acting within the
scope of duties of such relationship to The Salvation Army Kroc Center.
I HAVE CAREFULLY READ THIS LIABILITY AND FULLY UNDERSTAND AND AGREE TO ITS CONTENTS. I AM AWARE THAT BY SIGNING
THIS DOCUMENT, I AM GIVING UP CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE THE SALVATION ARMY.
I hereby certify that I have the authority to sign this document for the child/children identified on this Registration Form.
Parent or Legal Guardian’s Name (PRINT):____________________________________________________________________________________
Signature: _________________________________________________________________________ Date: _______________________________
Revised 5/1/201
Kroc Sports Camp
$75 per Camper
Monday - Thursday, 9:00am – 12:00pm
Volleyball Camp/ $100 per Camper
Monday- Tuesday, 9:00am-3:00pm
Wednesday, 9:00am-Noon
Baseball……………June 11-14th
(Ages 6-12yrs)
Basketball…………June 18-21st
(Ages 9-15yrs)
Football…………….July 9-12th
(Ages 9-15yrs)
Volleyball…………..June 25-27th
(Ages 12-18yrs)
For more information please contact The Kroc Center at
228-207-1218 or stop by 575 Division Street in Biloxi, MS
“Realize your Potential”
CAMPER CODE OF CONDUCT
Please take a moment to read this Camp Code of Conduct with your child. It is
important that both you and your child understand our expectations.
Campers must stay with their age group and be accompanied by the Camp Staff
during all Camp activities.
• Campers must remain on the Kroc Center premises at all times unless checkout by an authorized adult with.
• Campers are expected to respect other campers, the Kroc Center staff and the
facility at all times.
• Campers will not bring drugs or alcohol to camp.
• Campers will not bring weapons of any kind to camp, including small pocket
knives.
• Campers will not bring a cell phone, a portable game system or music player,
or similar items to camp
• The use of foul language, physical, verbal, or emotional violence and other
inappropriate behavior is strictly prohibited. The Kroc Center maintains a bullyfree environment.
• Shirts and shoes must be worn in all areas outside of pool and splash pad. No
swimwear is allowed outside of aquatic areas. Any logos or messages on
clothing must be acceptable in a family setting.
The Kroc center reserves the right to dismiss a camper without a refund who does
not meet behavior expectations.
Camper Name:
Parent Signature:
Date:
“Realize your Potential”
What to bring, What not to bring
Campers will receive
Football Camp
Athletic Shoes
Snacks if desired
Sunscreen
Shorts and T-Shirt
T-Shirt
Water bottle
Certificate of Completion
Baseball Camp
Bat
Glove
Batting helmet
Catcher’s equipment
Baseball attire and Hat
Snacks if desired
Sunscreen
Volleyball Camp
Basketball Camp
Appropriate attire Shoes
Appropriate Shoes
Gym Shorts
What not to bring
Cell Phone
IPods or other MP3 players
“Realize your Potential”