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Summer camp reg 2012 (1)

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Summer Camp Registration

Summer Camp Registration

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  • 1. W.E.L.C./R EFUGE A CADEMY S UMMER C AMP R EGISTRATION INSTRUCTIONS FOR FILLING OUT REGISTRATION FORM 1. PLEASE PRINT CLEARLY TO ENSURE ACCURACY OF INFORMATION. 2. Please make sure every area of the form is completely filled out. Uncompleted forms will not be accepted. 3. All applicable Registration Fees are due at the time of registration. 4. For Family information, please ensure both parents/guardians information is filled in. If the home address is the same for both then filling in “same as above” is acceptable. 5. Please make sure to give us a complete address (including city and zip code) and phone numbers (to include area codes). If you have a home telephone number please list under primary phone, if your cell phone is your primary phone then just list under cell phone. This is important to be able to get a hold of you in the event of an emergency and ensure that your bills and other announcements are received. 6. Please fill out driver’s license number and state as this is used for positive identification purposes. 7. Please fill out only TWO contacts for emergency. Please do not list yourself unless you are the only contact. Also, for specific instances if there is someone who is forbidden from picking up a child then please indicate that. This is for the protection of your child. 8. If you are military, please use Tricare if appropriate for insurance name and the parents SSN responsible for the account. Otherwise please give the information listed. 9. Please indicate whether you want your child to be photographed. 10. Please make sure all information for the children is filled out. This includes full name, birth date, grade, gender, and what your child prefers to be called. Also, please indicate what special needs or allergies your child has so we can help protect them. Then please indicate for which class and time you are registering for. 11. Please indicate who is responsible for payment. The person responsible for payment must sign form. 12. Please sign and date the application. Only one signature is needed. SCHOOL USE ONLY PLEASE:DATE DOCUMENTS RECEIVED: _________________________________[ ] REGISTRATION FORM:[ ] PAYMENT FOR REGISTRATION: 1|Page
  • 2. W.E.L.C./R EFUGE A CADEMY S UMMER C AMP R EGISTRATIONFAMILY INFORMATIONFather/Guardian First Name: M.I. Last Name:Address: City:_____________________ ST:________ Zip:________________Occupation: Primary Phone: ( )Employed By: Office Phone: ( )Driver’s License Number and State: Cell Phone: ( )Email:Marital Status: ____ Married ____ Single ____ Divorced ____ Widowed ____ SeparatedIf married, are you currently married to the child’s mother? Yes No If divorced, are you the custodial parent? Yes NoIs the person listed above allowed to pick up children? Yes No Is there any other information that would be helpful to ourmanagement and teachings staff? _____________________________________________________________________________________________________________________________________________________________________________________Mother/Guardian First Name: M.I. Last Name:Address: City:_____________________ ST:________ Zip:________________Occupation: Primary Phone: ( )Employed By: Office Phone: ( )Driver’s License Number and State: Cell Phone: ( )Email:Marital Status: ____ Married ____ Single ____ Divorced ____ Widowed ____ SeparatedIf married, are you currently married to the child’s father? Yes No . If divorced, are you the custodial parent? Yes NoIs the person listed above allowed to pick up children? Yes No Is there any other information that would be helpful to ourmanagement and teachings staff? _____________________________________________________________________________________________________________________________________________________________________________________EMERGENCY CONTACTS & AUTHORIZED PERSONS FOR PICKUPPlease give us the names of 2 people whom we can contact in the event of an emergency ifwe cannot get a hold of you. Please include an out of area contact if available.1st Contact/Pick-Up First Name: Last Name:Primary Phone: ( ) Relation to Child:[ ] Able to pick up all children in the family[ ] Restricted from picking up the following children:2nd Contact/Pick-Up First Name: Last Name:Primary Phone: ( ) Relation to Child:[ ] Able to pick up all children in the family[ ] Restricted from picking up the following children:*Is there anyone you are concerned about who might try to pick up your child who doesNOT have the right to take your child? No Yes ____________________________ 2|Page
  • 3. W.E.L.C./R EFUGE A CADEMY S UMMER C AMP R EGISTRATIONPHYSICIAN AND INSURANCE INFORMATIONPediatrician’s Name: Phone: ( )Name of Insurance Company:Policy Number (or SSN if Military): Group Number: _________Medical Release for Minor child/children:I, ______________________, Parent/Guardian of , , , a minorchild/children, hereby authorize any Medical or Surgical treatment necessary in an emergency, and in my absence, for the well beingof the above mentioned minor (s). I agree to hold Wasatch Early Learning Center, Good Foundations Academy, RefugeAcademy, all teachers and staff members, physician or hospital in treating the above mentioned minor (s), harmless. In case ofemergency, 911 will be called.Signature: Date: Photographs: May we take and maintain a photo of your child/children for security purposes, [ ] Yes [ ] No : For craft project, bulletin board, newsletters [ ] Yes [ ] No Website [ ] Yes [ ] NoStudent Information1st Child First Name: M.I. Last Name:Name child prefers to be called:Child’s Address: if different from parents: _______________________________ City:_____________________ ST:________Zip:________________ Gender: [ ] Male [ ] Female Date of Birth:Grade as of Sept 1_____________ Camper’s t-shirt size___________List any existing medical conditions, medication, allergies, and/or special attention your child may require?What are you registering this student for? Please mark all that apply to this student.[ ] Full Week Camp My child will not be attending weeks 1 2 3 4 5 6 7 8[ ] Tue/Thu only Camp [ ] Summer Bridge (additional $10/wk)[ ] Full Week Extended Care [ ] Hourly Extended Care 3|Page
  • 4. W.E.L.C./R EFUGE A CADEMY S UMMER C AMP R EGISTRATIONStudent Information2st Child First Name: M.I. Last Name:Name child prefers to be called:Child’s Address: if different from parents: _______________________________ City:_____________________ ST:________Zip:________________ Gender: [ ] Male [ ] Female Date of Birth:Grade as of Sept 12_____________ Camper’s t-shirt size___________List any existing medical conditions, medication, allergies, and/or special attention your child may require?What are you registering this student for? Please mark all that apply to this student.[ ] Full Week Camp My child will not be attending weeks 1 2 3 4 5 6 7 8[ ] Tue/Thu only Camp [ ] Summer Bridge (additional $10/wk)[ ] Full Week Extended Care [ ] Hourly Extended CareStudent Information3st Child First Name: M.I. Last Name:Name child prefers to be called:Child’s Address: if different from parents: _______________________________ City:_____________________ ST:________Zip:________________ Gender: [ ] Male [ ] Female Date of Birth:Grade as of Sept 12_____________ Camper’s t-shirt size___________List any existing medical conditions, medication, allergies, and/or special attention your child may require?What are you registering this student for? Please mark all that apply to this student.[ ] Full Week Camp My child will not be attending weeks 1 2 3 4 5 6 7 8[ ] Tue/Thu only Camp [ ] Summer Bridge (additional $10/wk)[ ] Full Week Extended Care [ ] Hourly Extended CareTUITION INFORMATION & PAYMENT AND BILLING INFORMATION 4|Page
  • 5. W.E.L.C./R EFUGE A CADEMY S UMMER C AMP R EGISTRATION The tuitions/fees will not be prorated to accommodate sickness, holidays, family vacations or school closures due to inclement weather or situations out of W.E.L.C.’s control.REGISTRATION FEES/STUDENT (due at registration): 10% tuition discount if paid in full by Aug 30th. Summer camp, byJune 1st. 10% Family discount if more than one child enrolled in school from the same family.Summer Camp/child registration per child: _____________ $25.00TUITION PER CLASS/STUDENT (Monthly Fee billed on the 1st and the 15th of each month and due within two weeks)Summer Camp: Program runs for 8 weeksFull Week: (8-3:30) Cost is $100.00 per week with a registration fee of $25.00 for a total of (825.00) per child. Initials ______Tue/Thu only (8-3:30) Cost 55.00 per week with a registration fee of $25.00 for a total of (465.00) per child. Initials ______Daily Rate is $20.00 per day Initials ______Camper Extended Care runs for 8 weeks and is available from 6:30am-9am and 4pm -5:30pm and is in addition to SummerCamp rates.Hourly Rate: $5.00/Hour Initials ______Weekly Rate: $50.00/Week Initials ______Late Fees: To assure your children are picked up on time a late fee will be assessed at $15.00 (per-child) for every 15 min you arelate. Initials ________Please outline below whose is responsible for payment of registration, tuition and fees. Please indicate if parents are divorced and splittuition payment or if tuition payment is the responsibility of an adult other than the parents listed above. All tuition and fees paymentsfor the following month are required, in advance, by the 20 of the current month. A late fee of $25 dollars will be assessed for latepayments and returned checks. Please make all checks out to WELC and include your student name on the memo line.SIGNATURES AND AGREEMENTSBy signing below, you are stating that this application is filled out honestly to the best of your knowledge. If you enrolled your studentin the Bible Explorers Program then you also authorize your student to be excused from Good Foundations Academy to attendreleased time religious instruction at the W.E.L.C./Refuge Academy Bible Explorers Program.All policies and procedures and conditions are explained in the W.E.L.C. parent handbook.[ ] Please check this box if you have received and read the information in the handbook.Signature: I agree to the conditions and polices of Wasatch Early Learning Center as stated in the Parent Handbook and thisregistration form.Parent’s Signature: Date:Parent’s Signature: Date:Responsible Payer Signature: Date: ______If other than Parent 5|Page
  • 6. W.E.L.C./R EFUGE A CADEMY S UMMER C AMP R EGISTRATIONWasatch E.L.C./Refuge Academy Summer Day CampFAIR PLAY POLICY & BEHAVIOR POLICYOur goal is to provide for personal growth in a safe environment. Please assist us in maintaining a safe and enjoyableenvironment by following the Fair Play Policy.Individuals using the Wasatch E.L.C. /Refuge Academy facilities are expected to: • Wear appropriate attire in recreation facilities, this includes a shirt and shoes. • Refrain from using profane language. • Refrain from placing themselves and/or others at risk (i.e. hitting, fighting, biting, kicking, spitting, etc…) • Respect one another and one another’s belongings. • When participating in recreation programs, remain with the instructors, following directions to the best of their • Ability and refrain from disrupting the class.Persons endangering the safety of themselves or others will be removed from the program.Other infractions of the rules will be handed as deemed necessary by the recreation staff.Children who misbehave or break camp rules will be given a series of check marks leading up to a “strike”. We reservethe right to bypass one or more steps in this process if a situation warrants it.Modifications to these rules may be made to accommodate individual needs.1st Offense: Child will be given a five (5) minute time out.2nd Offense: Child will be given a ten (10) minute time out.3rd Offense: A “strike” will be given.Not cooperating while disciplined will result in additional time added to a time out.1st Strike: Conference with Camp Director, Recreation Supervisor, child and parents.2nd Strike: Conference with Camp Director, Recreation Supervisor, child and parents, suspension from camp for 3 days.3rd Strike: Dismissed from camp with NO REFUND.Parent or Legal Guardian Signature: Date:Campers Name____________________________________________ 6|Page
  • 7. W.E.L.C./R EFUGE A CADEMY S UMMER C AMP R EGISTRATIONPolicy StatementPlease read these terms carefully. This form contains additional financial terms to the W.E.L.C./Refuge Academy Summer CampParticipation Agreement. It also contains a release for liability resulting from your childs participation in Refuge Academy SummerCamp Programs. By signing this form, you agree to all terms herein. W.E.L.C./Refuge Academy Summer Camp agrees to providesummer camp services for the dates/weeks listed on the W.E.L.C./Refuge Academy Summer Camp participation Agreements Inreturn, the financially responsible party for the above mentioned child agrees their child may participate in all scheduled activities andagrees to pay in full for the agreed upon dates/weeks. Refunds/Cancellation PolicyAfter W.E.L.C./Refuge Academy Summer Camp receives the Participation Agreement, no refund will be given for the registrationfee. Any camps registered for may be cancelled if notice is given 15 days prior to camp attendance. Within 45 days of attendancethere will be a minimum $50.00 cancellation fee. If no one is found to take your childs spot in camp, you may be charged the fullweekly tuition. In return, W.E.L.C./Refuge Academy Summer Camp agrees to hold a spot open for your child to attend camp forthe weeks registered. PaymentsRegardless of whether the above mentioned child ever attends any portion of camp, full payment of all fees for registered weeks is stilldue. Payments of camp must be paid in full or bi-monthly. I understand that if my account becomes past due, it may be sent to acollection agency and additional charges will be applied. If collection is made by such an agency or otherwise, I agree to pay allcollection costs including all attorneys fees and legal expenses. Credits for Illness/InjuryNo credit will be given for any days/weeks missed due to vacation, illness, family emergency etc. Suspension/Termination of Camp ParticipationI understand and agree that my child will abide by the citizenship rules and standards of Refuge Academy Summer Camp.I understand that my child may be dismissed for disciplinary reasons and/or safety of the other children and staff. If my child issuspended or expelled from camp for any reason, no refund or excuse for future payments will be made and all tuition will still beowed for programs which the child is registered for W.E.L.C./Refuge Academy Summer Camp agrees that suchsuspension/expulsion will not be arbitrary or capricious Transportation ReleaseI grant W.E.L.C./Refuge Academy Summer Camp permission to transport my child in any vehicle used for W.E.L.C./RefugeAcademy Summer Camp programs/purposes. I understand that this transportation may occur in any vehicle included. But not limitedto: Camp buses, vans, cars, or private vehicles. I herby release W.E.L.C./Refuge Academy Summer Camp its employees and agents,from any liability resulting from such transportation. Liability ReleaseI agree to release and discharge W.E.L.C./Refuge Academy Summer Camp and its officers, employees and agents from all causes ofactions, suits, debts and damages (both actual and punitive). damages from any personal property, suits or damages resulting fromillness or injury occurring while in the care of W.E.L.C./Refuge Academy Summer Camp, or claims or demands of any type or kindwhatsoever that may arise on account of programs of activities sponsored or coordinated by W.E.L.C./Refuge Academy SummerCamp. This release shall not apply to claims arising from willful misconduct or caused by gross negligence. Signature AuthorizationI/We have legal custody of this child and claim full financial responsibility for the above mentioned child. I/We fully read, understand.and agree to the above terms of this agreement.Parent/Guardian Name______________________________________________________________________Signature_________________________________________________________Date____________________General Information 7|Page
  • 8. W.E.L.C./R EFUGE A CADEMY S UMMER C AMP R EGISTRATION • Campers must be registered and paid in full prior to attending any session. • Lunch is not provided. Campers need to bring a packed lunch • Campers cannot be just dropped off. All campers need to be signed in and out daily by parent or guardian. Photo I.D. may be required when picking up a child. • Please send your child in comfortable clothing that can take outdoor play, painting, gluing, and getting really messy. • We ask that campers bring only what they need to camp (no Game boys, CD players, Pokémon cards, etc.). • Field trips are not part of camp tuition/registration at this time, because of this, our field trips will be limited and most activities will take place at the Bible Explores building or the CHS High school building. • No refunds will be granted. • No Camp or Extended Care Wednesday July 4th 2012. • Background checks for all parent volunteers are required. Expenses of background check are to be paid by volunteer requiring the background check. Reply promptly, as enrollment space is limited!Make checks payable to W.E.L.C.Please contact Director Ann Simpson withQuestions at 801-389-6942 or aajjrs@msn.comMail Registration Form and Payment to:W.E.L.C., 5099 S. 1050 W. Riverdale UT 84405 NOTICE OF NONDISCRIMINATORY POLICY AS TO STUDENTSWasatch Early Learning Center /Refuge Academy (5099 S. 1050 W., Riverdale) admits students of any religion, race, color, nationaland ethnic origin to all the rights, privileges, programs, and activities available to students at Wasatch Early Learning Center. Theschool does not discriminate on the basis of religion, race, color, national and ethnic origin in administration of its programs or of itseducational, admissions, or tuition policies. Wasatch Early Learning Center/Refuge Academy reserves the right to refuse service toanyone.Basic Camp Rules and Bus Skills 8|Page
  • 9. W.E.L.C./R EFUGE A CADEMY S UMMER C AMP R EGISTRATIONBy reading and understanding these important camp rules. We all have the opportunity to have a safe, fun camp experience. Pleaseread and discuss this form with your camper and send it back signed with your registration materials.Basic Camp RulesRespect (yourself, others, counselors, and property) Prohibited Camp ItemsUse appropriate words No cell phonesAlways ask to borrow No MP3/CD playersTreat each other kindly No electronic gamesTell the truth (no matter how hard) NO matches/lightersJUST BE NICE No inappropriate clothing/literatureZero Tolerance Discipline StepsNO obscene language/gestures 1st Offense: Child will be given a five (5) minute time out.NO weapons of any kind 2nd Offense: Child will be given a ten (10) minute time out.NO alcohol/drugs 3rd Offense: A “strike” will be given.NO sexual behavior Not cooperating while disciplined will result in additional time added to a time out.Basic Bus Rules 1st Strike: Conference with Camp Director, RecreationStay seated at all times Supervisor, child and parents.Use appropriate voice level 2nd Strike: Conference with Camp Director, RecreationKeep yourself and your belongings in the bus at all times Supervisor, child and parents, suspension from camp for 3Always listen to the bus driver! days.Leave the bus clean and in good shape 3rd Strike: Dismissed from camp with NO REFUND.Relax and enjoy the rideW.E.L.C./Refuge Academy summer camp asks that you be involved with your campers behavior in camp. It is important that yourcamper understands what is expected of her/him and the consequences of undesirable behavior. Please take the time to discuss thesethings with your camper and we will all have an incredibly successful camp experience. Thank you, and if you have any que4stions orconcerns regarding our policies and /or procedures, please contact our office at 801-389-6942Campers printed name ________________________________________________________________Parents Name ________________________________________________________________________Parents Name________________________________________________________________________ 9|Page