2010
YERWOOD EDUCATIONAL SUMMER (Y.E.S.)
REGISTRATION FORM
KINDERCAMP ID# _________ (Kindergarten
Students Only)
YES CAMP ID# ___________ (1st-
4th Grade Students)
IXCEL ID# __________ (5th
Grade Students Only)
Camper Information
Last Name: __________________________________First
Name: ____________________________________________________DOB______/______/______
Street Address: __________________________________________________________________________________________________
Apt # ________________
City: ____________________________________________
State: _____________________________________ Zip Code: __________________________________
Home Phone: ( ) _______
__________________________ Alternative
Phone: ( )_____________ __________________
Email Address: ________ ____________________________________
Gender (Circle One): Male Female Is your Child a Returning Camper?
(Circle One): Yes No
T Shirt Size (Circle One): Child: S M L XL
Adult: S M L XL XXL
Current School: _____________________________________________________________________________Current
Grade Level: ___________________
Parent/Guardian Information
Name:
___________________________________________________________________________Relationship
to Participant: ______________________
Street
Address: _____________________________________________________________________________________Apt
#: ____________________________
City:
__________________________________________________ State:
________________________________________ Zip Code: ________________________
Home
Phone: ( ) _____
____________
____________ Cell Phone: ( )
__ ___ ________ ______________________
Parent/
Guardian 2
Name:
___________________________________________________________________________Relationship
to Participant: ______________________
Street
Address: _____________________________________________________________________________________Apt
#: ____________________________
City:
__________________________________________________ State:
________________________________________ Zip Code: ________________________
Home
Phone: ( ) _____
____________
____________ Cell Phone: ( )
__ ___ ________ ______________________ Is the Above Person Authorized to
Pick-Up My Child at the End of Each Day or in the Event of an Emergency: Yes No
Employer
(if unemployed, write “None”): ____________________________Work Phone: ( ) _________________________________
Emergency
Contact Information
The
first attempt will be made to contact the camper’s parents/guardians. Emergency
Contacts listed below must be able to pick your child up in the event of an
emergency.
Emergency
Contact 1
Name:
___________________________________________________________________________Relationship
to Participant: ______________________
Street
Address: _____________________________________________________________________________________Apt
#: ____________________________
City:
__________________________________________________ State:
________________________________________ Zip Code: ________________________
Home
Phone: ( ) _______
__________
____________ Cell Phone: ( )
__ ___ ________ ______________________
Is
the Above Person Authorized to Pick-Up My Child at the End of Each Day or in
the Event of an Emergency: Yes No
Emergency Contact 2
Name:
___________________________________________________________________________Relationship
to Participant: ______________________
Street
Address: _____________________________________________________________________________________Apt
#: ____________________________
City:
__________________________________________________ State:
________________________________________ Zip Code: ________________________
Home
Phone: ( ) _______
__________
____________ Cell Phone: ( )
__ ___ ________ ______________________
Is the Above Person
Authorized to Pick-Up My Child at the End of Each Day or in the Event of an Emergency: Yes
No
Additional
Authorized Pick-up
1.____________________________________________________________________________________________________________________________________________
(Name)
(Contact #) (Relationship)
2.____________________________________________________________________________________________________________________________________________
(Name) (Contact #) (Relationship)
3.____________________________________________________________________________________________________________________________________________
(Name)
(Contact #)
(Relationship)
My child receives free or reduced lunch
during the school year.
My child will be receiving the
following camperships for the 2010 Yerwood Educational Program:
Care 4 Kids
Person 2 Person
Other
_________________________________________
None
List any
allergies/ medical conditions we should be aware of:
______________________________
_________________________________
_________________________________
___________________________________
In
case of a Medical Emergency: Does
Yerwood Center, Inc. has your permission to take your child to the hospital? YES NO
Photo Release
I hereby consent to the taking of
photographs, movies, Internet use, and videotapes of my child by Yerwood
Center, Inc. or its designated representatives. I also grant the right to edit,
use, and re-use said products for any and all educational, public service, or
not for profit purposes selected by Henry Street Settlement and release any and
all rights, title, and interest we or the child may have in said products.
Photocopies and facsimiles of this Release and consent shall have the same
legal effect as the original.
Grant
Permission Do
NOT Grant Permission Parent/ Guardian Initials: __ _______________
Pick Up Policy
I understand that
the Yerwood Center, Inc. is not responsible for children until they are signed
in the program either by a parent, guardian or authorized alternate (age 18 or
older). I understand the Yerwood Center, Inc.
is no longer responsible for the program participant once he or she has
been checked out.
I/We the
parent(s)/guardian(s) of the participant do hereby consent to his/her
participation in the Day Camp Program including all activities incidental to
the Program. I/We assume all responsibilities for, and risks and hazards of,
participation in the named Program. In consideration of the Day Camp Program,
including all officials, officers, sponsors, organizers, supervisors,
volunteers, participants, and all other agents, I/we the parent(s)/guardian(s)
release any and all claims, demands, rights, and causes of action of whatever
kind of nature, arising from and by reason of, and all known and unknown,
foreseen and unforeseen, bodily and personal injuries, damage to property, and
the consequences thereof, resulting from his/her participation in the Program
and all activities incidental to the Program.
I
understand the terms of the pick-up policy. Parent/ Guardian
Initials: _________________
Permission for Field Trips/
Swimming
I give Yerwood Center, Inc. permission
to transport my child on fieldtrips. I understand that I will be notified of
exact times and locations. My child is allowed to participate in free swimming
supervised by Yerwood Staff.
Grant
Permission Do
NOT Grant Permission Parent/ Guardian Initials: ____________________
Family Involvement Trip
Friday,
August 6, 2010, Yerwood Center will be hosting their second annual Family
Involvement Event to The Great Escape Amusement Park of Lake George, NY. I
understand this trip is an additional fee of $50.00 per person that is separate
for the regular camp. I understand that
my child must be accompanied by an adult to participate in this family involvement
activity. If my child does not attend this event, my child will not attend the
camp activities on that day.
My child and an
accompanying adult no younger that 18 years of age will be attending The Great
Escape Amusement Park on Friday, August 6, 2010. I will
pay the fee for this event no later than Friday, June 4, 2010.
My child will not
attend this event.
School and Report Card Information
I
herby give Yerwood permission to contact my child’s school to discuss my
child’s progress and obtain report card information.
Grant
Permission Do
NOT Grant Permission Parent/ Guardian
Initials: ________
Summer
School via Stamford Public Schools (July 5, 2010- July 30, 2010)
***Must be
approved by Stamford Public School that your child is attending.
My
child will be attending Stamford Public Schools Summer School Program at the
Yerwood Site. I understand that their camp day will not begin until 1:00PM
Monday-Friday and there will be no deduction in price.
My
child will be attending Stamford Public Schools Summer School Program at the
_________________________ Site. I understand that
their camp day will not begin until 1:00PM Monday-Friday and there will be no
deduction in price.
My child will not be attending Stamford
Public Schools Summer School Program.
Y.E.S.
Camp Rules