2017 BTB SUMMER CAMP WIL BE HELD AT GLENWOOD SPRINGS HIGH SCHOOL,
1521 GRAND AVE. GWS CO 81601 June 12-Aug 25th 7:30-5:30
www.beyondthebelldaycamp.com
PLEASE FILL OUT THIS FORM ONLY IF YOUR CHILD IS ATTENDING THE BEYOND THE BELL SUMMER PROGRAM
POR FAVOR COMPLETE ESTE FORMULARIO SOLO SI SU HIJO ATENDERA EL PROGRAMA DESPUES DE LA ESCUELA DE BEYOND THE BELL
STUDENT ENROLLMENT FORM~ Forma de Inscripción Estudian Enrollment Date: ______
Child’s Name:______Date of Birth: ______Age:_____
Days of the week child will be Attending Beyond the Bell: ______
Grade and Teacher:______
Child’s Home Address: ______
Parent’s Address if different than child: ______
Child’s Home Phone: ______Parents home phone if different than child: ______
Email ______
Mother’s Name:______Father’s Name:______
Work. No.: ______Work No.: ______
Cell No.: ______Cell No.: ______
Place of employment ______Place of employment ______
Work Address: ______Work Address: ______
IF neither parent of guardian can be reached, in case of emergency, call: List name, Phone numbers and address:
Persons authorized to pick-up your child : ______
Persons who are NOT legally permitted to pick-up your child: ______
Child’s Doctor include Number and address: ______
Dentist include Number and address: ______
Allergies and/or health concerns: ______
**Please attach a copy of current immunization records**
Authorization for child to view “G” and “PG” rated videotapes
I give my permission for my child to view “G” and “PG” rated videotapes at Beyond the Bell.
Dated:______By:______Signature of Parent or Guardian
Authorization for Child to Sign Himself/Herself in: I give permission for my child to sign him/herself in to the program. Beyond the Bell accepts no responsibility for ensuring the attendance and arrival of the child. As a courtesy, we attempt to contact parents by phone if their child does not sign-in to the program. It is the parent’s responsibility to ensure the classroom teacher, the child and Beyond the Bell know the days of attendance and that updated phone numbers are on file with the school and Beyond the Bell.
*additional form MUST be signed if your child will be signing themselves out at the end of the day.
Field Trip/Activity Authorization: I give my permission to Beyond the Bell and/or its employees to take my child on walking field trips, use of public transportation and school buses and for my child to participate in any of the activities associated with the program. I understand that my child’s participation in this program, in general, could involve various risks, hazards and dangers which may include risks of physical harm and injury due to participating in the activities or traveling to and from locations outside of the school facility. I understand that Beyond the Bell undertakes every reasonable effort to make the activities safe, but I also recognize that it is impossible to guarantee the safety of each individual involved in such activity or to guarantee that the activity will proceed exactly as planned. I hereby assume all risks that could be posed to my child and indemnify and hold harmless Beyond the Bell, its staff, agents and employees from any liability, claim, cause of action or demand arising from my child’s participation in this program.
Dated:______By:______Signature of Parent or Guardian
Medical Authorization: In case of serious illness or injury when neither parent can be reached, will you allow your child to be transported to the doctor or hospital by an employee of Beyond the Bell? ___YES ___ NO
I hereby give permission to Beyond the Bell to secure emergency medical and/or surgical treatment for the above named minor child while in the care of the above named school. All expenses of such care will be accepted by the parents. . I will hold the Beyond the Bell staff, agents and employees harmless and indemnify them from any claim, cause of action or demand arising out of any form of (or lack of) medical or emergency treatment rendered to the student.
Dated: ______By:______Signature of Parent or Guardian
Acknowledgement of Policies and Procedures: I have read and understood the policies and procedures of Beyond the Bell:
Dated: ______By:______
Signature of Parent or Guardian firma del Padre o Guardián
Please enclose $25 annual family registration fee. Make checks payable to Beyond the Bell.
Beyond the Bell~ Summer Liability Waiver Form
Dear Parents:
The following is a list of all field trips and/or special programs that are possibilities for the summer. Please initial in the space provided for those activities you will not allow your child to participate in. A weekly calendar will be provided with activity information. Please review these calendars as they will serve as reminders and help you to prepare for each week of Beyond the Bell. Beyond the Bell Staff will supervise all events.
______Swimming (Public Swimming Pools with lifeguards)
______GWS Center for Arts
______Adventure Park Rides
______Bowling
______Magic Show
______Mini-Golf
______Nature walks
______Biking – MUST wear a helmet
______Hiking
______Caving
______Fishing
______Challenge Course Activities/Zip Line
______Bananas
______Horse Back Riding
______Karate
______Cross fit
______Dance
______Sports
______Pottery
______Cheerleading
______Yoga
______Drama
______3-D Art
______Run Club
______Gymnastics
______Jewelry
______Cooking
______Nature Museum
______Zip Line
______Rafting
______Animal Shelters
______Frisbee Golf
______Library
______PG movies – previously screened by the Beyond the Bell Director
______Arts and Crafts
______Media Release –Permission to take photos of your child for media and promotion
______Transportation by school bus or public transportation or Beyond The Bell 15 passenger Van
______Walking field trips within the community
*If any trips other than the ones listed above are planned, Additional permission forms may need to be signed*
Most trips away from the site will be walking field trips. In addition Beyond the Bell may utilize the city public bus system to get to and from locations. Please be advised that at this time the buses are not equipped with seat belts. All applicable safety rules are given to the children every time they board the bus or begin a walk.Please sign the permission/waiver form below to indicate approval for the trips (with the exception of the ones you have initialed) for mode of transportation provided.
I give my permission for______to attend the above activities with the Beyond the Bell~ Summer program. I acknowledge that my child’s participation in this activity involves an inherent risk of physical injury to any individual undertaking such activity or damage to the property of such individual. The undersigned expressly assumes such risk and releases and waives any claims against Beyond the Bell Inc., its agents and employees, for any damages to persons or properties, whether the result of negligence, breach of warranty or otherwise. The undersigned further agrees to hold Beyond the Bell Inc., its agents and employees, harmless, for any injury to other persons or property caused by participant’s involvement in this activity. Furthermore, I hereby agree to release and hold harmless Beyond the Bell Inc. from any claim brought by a third party due to my participation in this activity. I understand that my child or I may be photographed and give permission for photographs to be used to publicize activities for the Beyond the Bell program. This agreement shall be effective and binding upon the parties hereto for the activities indicated. If I am signing this agreement of behalf of a minor child, I understand that the foregoing agreements and waivers shall apply equally to the child. Thus parties here to acknowledge having read and understood this agreement.
Attendance and Permission From~ (please fill out front and back of this form!)
Child’s Name: ______
Please check the option below that your child will be attending camp:
¨ Full Summer – 5 days per week all summer (54 days) June 12th-August 25th 2017
¨ 4 days per week ~ which days______
¨ 3 days per week ~ which days______
¨ 2 days per week~ which days______
¨ 1 day per week ~ which day______
¨ Random Days ~ please include a monthly schedule of days attending Payment Schedule: PRICE DOES NOT INCLUDE $25 Registration fee. Please pay Registration fee at time of registration IF YOUPAY IN FULL BY 4/30/17 For the whole summer you will receive a 10% discount.
A 10% sibling discount is available. Fees listed below are for the whole summer: (every day= 54days)
Full Summer: $2430($2187 if paid by 4/30)ALL 54 days must be attended to receive the full time rate
***Full Summer Payment plan… Due May 15th $810, June 15th $810 July 15th $810
4 days per week $2200($1980 if paid by 4/30)
*** 4 days per week payment plan… Due May 15th $750, June 15th $750 July 15th $700
3 days per week $ 1650 ($1485 if paid by 4/30) *** 3 days per week payment Due May 15th $ 550, June 15th550 $ July 15th $ 550 2 days per week days1100 ($990 if paid by 4/30)
*** 2 days per week payment … Due May 15th $400, June 15th $400 July 15th $300
1 day per week $550($495 if paid by 4/30)
*** 1day per week payment plan Due May 15th $200, June 15th $200 July 15th $95
DROP INS AVAILABLE @ $55 per day OR PREPAID DROP-IN PUNCH PASS 10 For $530
(On going classes kids have the choice to sign up for)
Multiple activities will always be offered, (3 different activities going at a time)
MONDAYS: SWIMMING AND SPORTS CAMPS TBA
TUESDAYS: LIBRARY, Biking Other Classes TBA
WEDNESDAY: HIKING AND FIELDTRIPS TBA
THURSDAYS: Extra Curricular Activities, Other Classes TBA
FRIDAY: PARK DAY, Classes, Movie afternoon TBA
Beyond the Bell~Summer Permission Form
Sun Screen and Bug Spray:
I will allow Beyond the Bell staff to apply sunscreen (supplied only by me) and Bug Spray (supplied only by me) to my child prior to outside play.
______
Signature Date
Illness Policy
I will not allow my child to attend if he/she becomes exposed to any contagious disease, or if, for any reason, I do not consider my child to be in good physical condition.
______
Ø Signature of Parent or Guardian
Acknowledgment of Policies & Procedures:
I have read and understood the Policies & Procedures of Beyond the Bell Summer Camp as well as payment requirements and attendance cancellations.
Dated:______By:______
Signature of Parent or Guardian
459 Rio Grande Ave.
New Castle CO. 81647 (BEYOND THE BELL OFFICE ADDRESS) 707-631-3993 www.beyondthebelldaycamp.com