CAMP_REGISTRATION_FORM+2015 w discount
Transcription
CAMP_REGISTRATION_FORM+2015 w discount
REACH OUT AND TOUCH SUMMER CAMP REGISTRATION FORM How to register your child -‐ don’t be disappointed, camps fill quickly -‐ register early Four groups (Ages 4, Ages 5-‐7, Ages 8-‐10, Ages 11-‐14) 1. Complete both sides of this form and drop off or mail with one 4me registra4on fee of $25 to Reach Out and Touch, Post Office Box 3966, Shreveport, LA 71133. You will receive a confirma4on (phone or email) within one week of receipt of registra4on. If you do not hear from us, please call 318-‐210-‐8352 or 318-‐682-‐3850. We will only accept 100 children. Payment of registra4on and ac4vity fee will secure your child a place in this camp. Registra4on fees are non-‐refundable. ⁿZ \Z 2. Camp fees are $110. If your child qualifies for the sliding fee discount, rates are $55 per week, 2 child -‐ $45, 3 child $35. A one-‐4me $25 registra4on fee is required for each camper for the 2015 camp season (includes-‐T-‐shirts). Camp hours: 7:30a – 5:00p June 1 – August 7, 2015. Late pick up fee (a`er 5:30pm) is $15 per hour per camper. Child’s Name:____________________________________________Age:_______ Shirt Size: Youth □S □M □L Parent’s Name:___________________________________________Phone:____________________________ Home Phone(s):_______________________________ Cell Phone(s):__________________________________ Guardian(s):___________________________________________ Rela4on to Child:______________________ Address : _________________________________________________________________________________ Work Phone(s):_____________________________________________________________________________ Email: ___________________________________________________________________________________ 3. Camp ac(vi(es (tenta(ve calendar) are a4ached. Please put a line through ac(vi(es which you choose for your child to not a4end or par(cipate in. A one-‐(me $100 fee is required for each camper for the 2015 camp season and is due prior to child a4ending camp. Deadline for payment is June 1, 2015. Authorization and Consent As parent, legal guardian or agency representing the child named above, I hereby give consent to enroll my child in the specified program(s) operated by Reach Out and Touch. I have enclosed the proper deposit and will complete all payments and forms by the stated deadlines. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. I recognize that my child must follow safety instructions, remain in areas designated by staff, and refrain from behavior that is harmful to him/her or others. Failure to do so will result in dismissal from program without refund. Reach Out and Touch staff will do its best to ensure a safe experience, however I understand that accidents do occur. I hereby release Reach Out and Touch from any and all responsibility and liability of any nature resulting in my child’s participation in any program accident including claims for any injury, illness, loss or damage. My signature gives Reach Out and Touch permission to use all photos and videos taken during programs for promotional purposes. To opt out of this, I will submit request in writing. I have informed camp staff of my child’s medical conditions. All information given is accurate and true to the best of my knowledge. Parent/Guardian Signature: ________________________________________ Date: __________ Emergency Contact:___________________________ Phone:______________________________ In the event that neither I nor my designee cannot be contacted at the time of a medical emergency, I consent to emergency treatment determined necessary by a qualified physician. Parent/Guardian signature:_______________________________Date:______________________ CHILD INFORMATION SHEET Child’s Name:____________________________ Date of Birth:___________________________ Parent/Guardian Name: ___________________________________________________________ Address: _____________________________________________________________________ Phone: __________________________ Email: ________________________________________ HEALTH HISTORY OF CHILD: This is kept confidential. Attach additional sheet if necessary Please list any allergies:___________________________________________________________ Describe your child’s allergic reaction:________________________________________________ Other medical concerns:___________________________________________________________ Medications being used:___________________________________________________________ Please note that Reach Out and Touch cannot dispense any medications. Do not send any medications to camp with your child. Does your child wear: glasses( ), contact lenses( ), hearing aid( ), corrective shoes( ), prosthesis( )? Any other information concerning your child’s health that we should be aware of:___________________________________________________________________________ Child’s Physician: ___________________________________Phone #_______________________ Child’s Dentist:____________________________________ Phone #_______________________ My child has no condition that would prevent him/her from participating in the program or that the program’s normal activities would aggravate: Yes( ), No( ). If yes, explain in detail on an attached additional sheet. Is your child up-to-date on all state-required immunizations? Yes No Is the participant covered by family medial/hospital insurance? Yes No INSURANCE INFORMATION Is the participant covered by family medial/hospital insurance? Yes No Carrier or Plan Name: _____________________ Group #: _____________________ Address _______________________ City _____________________State ______ Zip Code ________ Name of Insured: _________________________ Relationship to participant: ___________________ RELEASE INFORMATION: Under no circumstances will a child be released to anyone without your written authorization. release to the following individuals. Photo identification is required for I give authorization for the following people to pick my child up from Reach Out and Touch’s programs: Name:_________________________Relationship:____________Phone:_____________________ Name:_________________________Relationship:____________Phone:_____________________ If applicable, please specify any individuals for whom there is a restraining order or custody restriction: _____________________________________________________________________________ Unless we have a copy of a court order prohibiting the release of a child to one of the child’s parents, it is legal for your child to be released to either parent. **CAMP WILL BE HELD AT Liberty Church, 6703 Melara Avenue, Shreveport, L A. 71108** UV Central Office: Reach Out and Touch, 3017 West 70 Street, Shreveport, LA 71108