Camp Fire Extended Day Programs

2016-2017

CAMP FIRE EXTENDED DAY PROGRAMS

Youth REgistration / Health history FORM

YouthINFORMATION

LastName: / First Name: / Middle: / Gender:
 M  F / Age: / Birth date:
Street Address: / City: / State: / Zip: / Phone Number: / School: / Grade:
Demographic information is desired only for statistical purposes. Responses will not affect the applicant’s qualification to enroll.
Ethnic/Racial:
 African-American  Hispanic  Caucasian
 Native American  Asian  Other ______/ Total # in Family:
 2 – 3 4 – 5
 6 – 8 Over 8 / Household Income:
under $15,000 $35,001 - $45,000
 $15,001 - $25,000  $45,000 - $55,000
 $25,001 - $35,000  over$55,000
Disabilities:
 Physical:______
 Developmental:______/  Other: ______
______

Parent / Guardian Information

Parent / Guardian Name: / Primary Phone: Secondary Phone: / Address if different from child:
Parent / Guardian Name: / Primary Phone: Secondary Phone: / Address if different from child:
Persons authorized to pick up my child: Name & Relationship: Name & Relationship:
Persons NOT authorized Name & Relationship: Name & Relationship:
to pick up my child:

IN CASE OF EMERGENCY

Name of local friend or relative (not living at same
address): / Relationship to youth: / PrimaryPhone: / SecondaryPhone:
Name of local friend or relative (not living at same address): / Relationship to youth: / Primary Phone: / Secondary Phone:

Medical Information

List of activities my child cannot participate in: ______

List any allergies or physical/health limitations:______

______

Medications: ______

Youth Health History - Please indicate Yes or No on each line:

Frequent Colds: ______

Frequent Sore Throats:______

Heart Trouble: ______

Convulsions:______

Abscessed Ears: ______

Athlete’s Foot: ______

Fractures:______

Fainting:______

Stomach Upset:______

Constipation: ______

Diabetes: ______

Rheumatic Fever: ______

Tuberculosis: ______

Kidney Trouble: ______

Chicken Pox:______

Measles: ______

Sinusitis:______

Mumps:______

Poliomyelitis:______

Whooping Cough:______

Hay Fever: ______

Skin Allergies:______

Bronchitis: ______

Serious Ivy or Oak:______

Poisoning:______

Other: ______

Other:______

The Commonwealth of Massachusetts

Department of Early Education and Care

Child’s Enrollment Form

Child Information

Child’s Name:______Date of Birth:______

Age at Admission:______Date of Admission:______

Child’s Home Address:______

Home Phone Number:______

Primary Language:______Identifying Marks:______

Eye Color:______Hair Color:______Skin Color:______

Sex:______Height:______Weight:______

Parent/Guardian Information

Parent/Guardian Name: ______

Relationship to Child:______

Home Address:______

Reachable Phone Number:______

Email Address:______

Business Name:______

Business Address:______

Business Phone Number:______

Hours at Work:______

Parent/Guardian Name:______

Relationship to Child:______

Home Address:______

Reachable Phone Number:______

Email Address:______

Business Name:______

Business Address:______

Business Phone Number:______

Hours at Work:______

Additional Information

Child’s Physician:______

Address:______Phone Number:______

Allergies/Special Diets?______

Individual Health Plan for child with a chronic health condition? If yes, please attach.______

Copies of any custody agreements, court orders, and restraining orders pertaining to the child? If yes, please attach.______

Special limitations or concerns? ______

______

School Age Only

Current School:______

School Address:______School Phone Number:______

I certify that documentation of physical examination and immunizations in accordance with public school health requirements and lead poisoning screening in accordance with public health requirements are on file at my child’s school. Parent/Guardian initials:

______

Parent/Guardian Signature Date

THE COMMONWEALTH OF MASSACHUSETTS

Department of Early Education and Care

FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM

Child's Name: ______Date of Birth: ______

I authorize staff in the child care program who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate.

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and/or to ______, and to secure necessary medical treatment for my child.

Child's Physician Name: ______

Address: ______

Phone Number: ______

Child's Allergies: ______

Chronic Health Conditions: ______

Emergency Contacts (In order to be contacted)

Name______

Address______Relationship to child______

Home Phone______Cell Phone______

Do you give permission for child to be released to this person? Yes_____ No______

Name______

Address______

Relationship to child______

Home Phone______Cell Phone______

Do you give permission for child to be released to this person? Yes_____ No_____

Name______

Address______

Relationship to child______

Home Phone______Cell Phone______

Do you give permission for child to be released to this person? Yes_____ No___

______

Parent /Guardian Signature Date (valid for one year)

THE COMMONWEALTH OF MASSACHUSETTS

Department of Early Education and Care

Small Group and Large Group Transportation Plan and Authorization

CHILD’S NAME:______

MY CHILD WILL ARRIVE AT THE PROGRAM:MY CHILD WILL DEPART FROM THE PROGRAM:

___PARENT DROP OFF___PARENT PICK UP

___SUPERVISED WALK___SUPERVISED WALK

___UNSUPERVISED WALK___UNSUPERVISED WALK

___PUBLIC/PRIVATE/VAN___PUBLIC/PRIVATE/VAN

___PROGRAM BUS/VAN___PROGRAM BUS/VAN

___CONTRACT/VAN___CONTRACT/VAN

___PRIVATE TRANS. ARRANGED BY PARENT___PRIVATE TRANS. ARRANGED BY PARENT

___OTHER___OTHER

I give permission for my child to be released from the program at the end of the program day as stated above and/or I give permission to the following people to receive my child at the end of the day. (If no one is authorized other than the parent/legal guardian, please indicate below “NO ONE.”)

If a child is protected by a restraining order please submit order to the provider.

Name______

Relationship______

Address______

Reachable Phone number (cell) ______

Name______

Relationship______

Address______

Reachable Phone number (cell) ______

Name______

Relationship______

Address______

Reachable Phone number (cell) ______

PARENT /GUARDIAN SIGNATURE______DATE______

REFER TO FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM FOR RELEASE INFORMATION

Camp Fire North Shore Extended Day Programs

Parent Contract 2016 - 2017

I, ______, am enrolling my child(ren)

Parent/Guardian

______in the Camp Fire North Shore Extended Day

Name(s)

Programs at a rate of $7.00 per day for before school care (at applicable schools) and $19.00 per

day for after school care. I am enrolling my child(ren) in the following [check all that apply]:

Before school: Mon_____Tues_____Weds_____Thurs_____Fri_____

(Only Shoemaker and Harrington will offer before school programs in 2016-17)

After school: Mon_____Tues_____Weds_____Thurs_____Fri_____

Children can be enrolled in before school, after school, or both. A minimum of two days for each type of service you enroll in (morning or afternoon) is required.

The total weekly rate per child that I agree to pay is: $______until the last day of the 2016-2017 school year, unless two weeks notice in writing of termination from program OR request in PERMANENT change in the child’s schedule is submitted.

I enter into this contract with the full knowledge of my obligation and my agreement to meet the following policies of Camp Fire North Shore:

To complete a child registration packet and pay a non-refundable $20.00 per child /$30.00 per family annual registration fee. The registration packet must include all pertinent information related to the safety of my child and I agree to update all of the information as necessarythroughout the year. This includes changes in phone numbers, address, medical history, emergency contacts, etc.

To pay tuition the Monday before my child attends the program at the above rate whether or not my child is in attendance. This is a full week in advance. This includes when my child is out sick and vacation time when the program is open.

I will be required to pay a late fee of $10.00 per fifteen minutes if I do not pick up my child by the closing of the program. Continuous tardiness could result in termination of my child from the program.

I understand that I am not obligated to pay for scheduled holidays and school vacation days. I am responsible to pay for up to three snow days per year. I also understand that Early Release Days incur an additional charge of $5.00 per child and is due with that week’s tuition.

I further understand that if I fall behind in tuition payments, the Camp Fire Extended Day Programs will terminate my child’s participation in the program, effective immediately. This action will not alter my obligation to pay the balance due.

I agree to call the Camp Fire Office or the Camp Fire school site if my child will be out sick or is going to be absent.

I authorize Camp Fire North Shore to photograph/video my child while involved in after school activities. I understand these pictures will only be used for Camp Fire promotion, marketing and for after school projects. INITIALS _____

______

Parent/Guardian Signature Date