Summer Camp Registration Form
Camper(s) NameAge & Birthday Grade completed in 2015
1)______
2)______
AddressCityZip Home Phone
______(____) _____-______
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Contact information: Email:______Text: (____) ______-______
Parent / WorkCell
Guardian: ______(____) _____-______(____) ______-______
Parent / WorkCell
Guardian: ______(____) _____-______(____) ______-______
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Emergency Contacts - Authorized to pick camper (Attach additional names, if necessary)
NameRelationship Phone
______(____) ______-______(____) ______-______
______(____) ______-______(____) ______-______
Code Wordfor pick up from camp or extended care______
Source: How did you hear about our camp?______
Shirts: CSY Summer Camp t-shirts are available for $5. These shirts will not be required for field trips.
____ YS ____YM ____YL ____YXL ____ S ____M ____L ____XL
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If you plan to register more than one camper, please mark each camper’s first initial on the days you plan to have them attend.Week of M TW TH F
6/15 Atlantis______
6/22Sea Creatures______
6/29 Pirates______
7/6Oopy Goopy______
7/13CEF camp***______
7/20 Shipwrecked______
*** CEF Camp *** EEC camp and Extended Care will operate as normal while Elementary campers enjoy activities planned by trained Child Evangelism Fellowship staff members.7/27Christmas Island______
8/3 Sunken Treasure______
8/11 A Star is Born______
Office Use Only:Allergy / Attendance / Code word / Email / Field Trip / Financial / Pool
Medical Information: The intent of this section is to provide camp personnel with background information to administer appropriate care. Any changes to this form should be provided to the camp personnel as soon as possible. Please provide complete information so that the camp can be aware of your child(ren)’s needs.
InsurancecompanyGroup # Policy Holder
______
Family Physician/Pediatrician Phone# Preferred Hospital Date of last Tetnus Shot
______
Allergies - List all known allergies, including but not limited to: medication, food, environmental, including insect stings, animal dander, etc., reaction and management of the reaction. Please attach additional sheet if necessary.
______
______
Medications - Please list ALL medications (including over-the-counter or non-prescription drugs and vitamins) that are taken routinely. Please attach additional sheet if necessary.
______
______
Please note any behavioral, learning or developmental issues so that our staff may be properly prepared for the success of your camper. (Please attach additional sheet if necessary.)
______
______
Parental Consent and Medical Authorization - This camper registration and health history is correct and complete as far as I know. I give permission for thecamper(s) named on this registration form to engage in all camp activities except as noted.
Although the camp desires to provide a safe and enjoyable time for all campers, there is always the possibility of an accident occurring. I understand that there are risks/dangers involved with participation in camp activities and their off-campus trips. In consideration of my child(ren) being allowed to participate in this event, I assume responsibility for those ordinary and reasonable risks associated with the travel and activities. I agree that Christian School of York its affiliated organizations, employees, agents, and representatives, including camp director, teachers, volunteers and drivers, will be held harmless from any and all claims of intentional (criminal) misconduct or gross negligence by the school, its employees, or volunteers. If such circumstances are proved in a court of law, I acknowledge and agree that the school can assume no financial liability beyond its actual liability insurance policy in force.
In case of accident, illness, or other emergency, I request that the school contact me. If the school cannot reach a parent/guardian after conscientious effort, I give permission for the school staff to call paramedics or any licensed physician or dentist. If a life-threatening emergency exists, I give permission for school staff to immediately call paramedics and then contact me/us as soon as possible thereafter.
I authorize and consent to any X-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care which, in the best judgment of a licensed physician or dentist, is deemed advisable. I agree to assume the financial responsibility for expenses incurred as a result of those services being provided. I also agree to be financially responsible for emergency medical transportation. Every effort will be made to contact parents.
Parent/GuardianSignature ______
Printed Name ______
Date ______
Pool Membership–First grade and higher: My child is a member at Green Valley Pool. Circle: Yes No
Parent/Guardian Signature ______Date______
Pictures - I give permission for photos taken of my child to be used on the CSY website and camp programming. Circle: Yes No
Parent/Guardian Signature ______Date ______
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Evacuation Procedures - In the event of an emergency that requires that the buildings to be evacuated, I authorize the Christian School of York staff member in charge of the Summer Camp program to transport my child to the old Central High School, 300 E. 7th Avenue, York, PA. Campers will be released to only parents / guardians or those listed as emergency contacts.
Parent/Guardian Signature ______*****************************************************************************************************************
Acknowledgement Receipt –Please initial beside each statement and sign below.
See handbook for specific policies.
- _____ I agree to adhere to the Christian School of York’s Summer Camp Policies and Camp Rules.
- _____ I understand that late payments may prevent my camper from attending camp.
- _____ I understand that continued behavioral issues may prevent my camper from attending camp..
______
Signature of Camper’s Parents/Legal Guardians Date
______
Signature of Camper(Elementary Campers only) Date
Campers will be considered registered upon receipt of this form as well as the non-refundable registration feeper camper:
$25 for one week of camp attendance or $50 for more than one week.
Cut off the below and save for future reference:
6/15 Atlantis
6/22 Sea Creatures
6/29 Pirates
7/6Oopy Goopy
7/13CEF camp***
7/20 Shipwrecked
7/27 Christmas Island
8/3 Sunken Treasure
8/11 A Star is Born
Camp phone: 683-3827
Director: Stephanie Hodges
-Weekly invoices will be emailed.
-Payment due the first day of each week attended.
-Extended Care available from 7:00 a.m. until 6:00 p.m.