Children’s Summer Day Camp Registration

Child & Youth Program

Name: Name: First Last
Date of Birth: Date of Birth: / MM / DD YYYY
Age:
Gender:

Gender: Female Male I prefer to self describe below
Address Address
Street Address Address Line 2 City Postal / Zip Code
Require Transportation?

Require Transportation? Yes No
If yes:
Allergies:

Allergies: Yes No
If yes:
Special Needs:

Special Needs: Yes No
If yes:
Group:

Group: Group 1 - ages 6 to 8 July 7-17 Group 2 - ages 9 to 12 July 21 -31 Group 3 - ages 6 to 8 August 5-14
Parent(s)/Guardian(s) Information:
Parent/Guardian 1: Name: Parent/Guardian 1:

Name: First Last
Phone Phone - ### - ### ####
Email
Preferred Method of Contact:

Preferred Method of Contact: Call Email Text Facebook
Facebook: (If different from above)
Parent/Guardian 2: Name: Parent/Guardian 2:

Name: First Last
Phone Phone - ### - ### ####
Email
Preferred Method of Contact:

Preferred Method of Contact: Call Email Text Facebook
Facebook: (If different from above)
In the case we cannot contact either parent or guardian, is there someone else you would like to list as an alternate contact/pick-up person? Name: In the case we cannot contact either parent or guardian, is there someone else you would like to list as an alternate contact/pick-up person?

Name: First Last
Contact # Contact # - ### - ### ####
Relationship
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Full Name

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Date Date / MM / DD YYYY
PARENT(S)/GUARDIAN(S), please read over the following rules with your child(ren). Children’s Programming will be implementing a “3 Strike Policy”. Any violation of these rules, the child will receive a strike. First strike given will be a verbal warning. Second strike is a written notice that will be given to the parent/guardian to talk to their child. Third strike will be dismissal from Children’s Programming. The length of time a child will be dismissed from programming will depend on severity of each incident.

1. Treat other participants, staff and guest facilitators with RESPECT.

2. Bullying, name calling, fighting, and arguing will not be tolerated

3. Listen and follow directions given by staff.

4. Please stay within the designated program area (no running around the halls) 5. Treat program equipment, supplies, and facilities properly and with care.

6. Do not touch food, supplies or equipment that do not belong to Children’s Programming. 7. Please clean up after yourself.

8. Keep hands, feet and other objects to oneself.

9. Participants will not use rude language (swearing, racist, homophobic, etc...)

10. Please ask a staff member to use the bathroom as only one participant is allowed at one time.

11. If a parent would like to attend program with their child, please only tend to your own child.

12. No cellular devices or other electronics are permitted. Please take them when you drop off. We understand the need to keep in touch with your child. Should you need to speak with him/her, or your child need to speak with you, a member of our staff is available to connect you by phone.

I
First Last
parent/guardian of
First Last
have read and understand the above rules. I assume the responsibility for ensuring that my child is aware of these rules and understands the consequences if they do not behave appropriately.
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Name Name First Last
Date Date / MM / DD YYYY
Draw your signature into the box below. (Parent 2)

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Name Name First Last
Date Date / MM / DD YYYY
Children’s Wellness Photo Release Form

I,
Name Name First Last
hereby grant permission to Children’s Wellness Worker to take photographs and/or video of my child(ren)
Name Name First Last
I understand that the images may be used for, news releases, websites, social media, presentations and/or program promotion.
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Date Date / MM / DD YYYY

Children’s Summer Day Camp Registration

Children’s Summer Day Camp Registration

Parent(s)/Guardian(s) Information:

Children’s Wellness Photo Release Form