Mount Hope Academy Summer Program

SUMMER

Registration

Activities Include

Field trips, Outdoor/Indoor Games, Nature Hikes, Sports, Swimming,

Reading, Math and Science Enrichment,

Arts and Crafts

3 – 5 year olds

6 - 7 year olds

8 – 12 year olds

Hours of Operation: 5:30AM – 4:00PM, After care 4:00PM – 6:30PM

Breakfast, Lunch & Afternoon Snack Served

Please Provide a Morning Snack, and Water Bottle Daily

Revised February 2013

MOUNT HOPE ACADEMY SUMMER PROGRAM

Student Information

Student’s Name______Birthdate______Age______

Mailing Address ______Sex of Child______

Home Phone______Business Phone______

School where registered______

Mother______Employer/City/Phone______

Cell phone______email______

Father______Employer/City/Phone______

Cell phone______email______

Emergency contacts (You must list two other than parents)

Name/Relationship/Phone______

Name/Relationship/Phone______

Person(s) Authorized to Pick Up Child

Person(s) Not Authorized to Pick Up Child

Physician Name/City/Phone______

Food/Drinks prohibited______

Allergies______

Special Needs/Regular Medications______

For children who were enrolled in public school, please provide an up-to-date copy of their immunization record.

For children 3-5 years of age and those who were not enrolled in public school a physical may be required as well as and up-to-date copy of their immunization record.

Medical Release

I hereby give my consent, in the event of a medical emergency when I cannot be contacted, for staff of Mount Hope Academy Summer Program to obtain whatever treatment may be deemed necessary for my child by a physician in any hospital emergency department.

Signature______

Relationship______Date______

ALLERGY RELEASE FORM

I HEREBY NOTIFY THE STAFF OF Mount Hope Academy that my child ______

is allergic to the following substances:

______

______

______

And could suffer a negative reaction if exposed to the above substances. Attached is a Physician’s Verification of this allergy.

I understand that the staff will to the best of their ability monitor any food my child eats or is exposed to, and I hereby release Mount Hope Academy and its staff from any liability which may result from my child’s accidental exposure to such foods.

I authorize the staff of Mount Hope Academy to administer the following medications to my child on an emergency basis to alleviate reactions to the above foods:

______

______

______

______

I understand that it is my responsibility to assist in the training of emergency care required by my child and that the staff will to the best of their ability follow the procedures. I release Mount Hope Academy and its staff from any liability, which may result from the administration of the above medication.

Signature: ______

Date: ______

Notarized seal: ______

CONSENT FOR EMERGENCY TREATMENT

I give my consent to the personnel of Mount Hope Academy to give emergency treatment to my child in the event of illness or injury, while he/she is at Mount Hope Academy.

I understand that only emergency treatment will be given and that I am responsible for follow-up treatment if needed.

Child’s Name: ______Age: ______

SIGNIFICANT MEDICAL HISTORY:

Allergies: ______

Unusual Drug Response: ______

Medication: ______

Epilepsy: ______

Rheumatic Fever: ______

Heart Disease: ______

Other: ______

______

Parent or Guardian Signature Date

______

Work Phone Number

______

Home Phone Number

NOTARIZED: ______

MEDICAL CONSENT FORM

Completion of this form is voluntary however; the penalty for not completing it may be a delay of processing or denial of admission. This information is gathered to promote the health and safety of all children enrolled.

Child’s Name: ______DOB: ______

Address: ______

______

Parent’s Name: ______

Day Telephone Number: (Mother) ______(Father) ______

Emergency Contact: ______Tel No.: ______

Physician or Clinic: ______

(Name)(Address)

Date: ______

1. I hereby give consent for Mount Hope Academy:

a. To obtain necessary medical information

b. To provide emergency medical care in the event that neither parent nor guardian can be reached.

2. I also acknowledge as my responsibility and consent to make available to my child when and if necessary, later:

a. A complete physical examination, including urinalysis, hematocrit, and follow-up care.

b. A TB skin test

c. Childhood shots, pertussis, tetanus (DPT), smallpox, polio vaccine, and measles vaccine.

d. Psychological evaluation and treatment.

e. Vision, hearing and dental services

Signature: ______Date: ______

Notarized: ______

Mount Hope Academy’s Decision to Administer Medications Plan

Mount Hope Academy has made the following decision regarding the administration of medications to a child in our program:

We WILL administer prescription and non-prescription medications. Medications will be administered by a staff member who has taken MAT (Medication Administration Training) at 10:00 a.m. and 3:00 p.m.Please adjust your child’s medication schedule accordingly. We will not be able to administer medication at any other time. A parent/guardian/custodian may come to the Academy at any time to administer his/her child’s medications.

If your child is on any medication, which needs to be administered while he/she is at school, he/she must have on file in the office the authorization for administration form. This form must be updated every six months for long-term medication and every ten days for short-term medication. This form is available in the Academy office and online at It must have the physician’s signature (if administered more than 10 days). The medication to be administered will be kept in a locked cabinet in the Academy office. The medicine must be in the original container. Over-the-Counter medication should be labeled with the child’s first and last names. Prescription Medication should be in a child resistant container. It must have the original pharmacy label that includes the following items: (1) Child’s first and last name, (2) Doctor’s Name, (3) Pharmacy name and telephone number, (4) Date Prescription was filled, (5) Name of Medication, (6) Dosage of the medication, (7) Route of administration, (8) How often to give the medication, (9) Date the medication is to be discontinued or length of time, in days, the medication is to be given. Parents must provide administration tools, such as dosing spoons, oral medication syringes, pill crushers, etc. STUDENTS MAY NOT TRANSPORT MEDICATION TO AND FROM SCHOOL.

Authorized Staff to Administer Prescription Medications

MHA will administer prescription medication in accordance with the physician’s or other prescriber’s instructions and in accordance with the MAT standards of practice. Only a provider who has successfully completed MAT or has appropriate licensure to administer prescription medications and is listed as a medication administrator in this plan will be permitted to administer prescription medications at MHA.

We understand that any individual listed in this section as a medication administrator is approved to administer prescription medications using the following routes: topical, oral, inhaled, eye, and ear, medication patches and epinephrine using an auto-injector device.

We understand that if a child enrolled in MHA requires prescription medication to be administered rectally, vaginally, by injection or by another route not listed above, I will follow the procedures outlined in MAT for children with special health care needs.

We understand that to be approved to administer prescription medication, all individuals listed in this plan (unless the individual is licensed to administer prescription medications) must have a valid:

• Medication Administration Training (MAT) certificate;
• CPR certificate which covers all ages of the children MHA is approved to care for as listed on our registration; and
• First aid certificate which covers all ages of the children MHA is approved to care for as listed on our registration.

Medication Administrators

MAT certificates (or documentation of licensure to administer prescription medication), age-appropriate first aid certificates, and CPR certificates for the staff listed below will be kept on site and be available upon request.

Corliss Shepherd Ruby Houston

Sharita Minor Tisha Thrash

Sophia Byrd Emyli Shepherd

Confidentiality Statement

Information about any child at MHA is confidential and will not be given to anyone except VDSS’ designees or other persons authorized by law unless the child’s parent or guardian gives written permission. Information about a child enrolled in MHA will be given to the local department of social services if the child receives a day care subsidy or if the child has been named in a report of suspected child abuse or maltreatment or as otherwise allowed by law.

Rehabilitation Act of 1973

We understand that if MHA receives any federal funding (such as child care subsidy from a local department of social services), We are subject to Section 504 of the Rehabilitation Act of 1973 which is similar to the provisions of the Americans with Disabilities Act. If a child enrolled in MHA now or in the future is identified as having a disability covered under the Rehabilitation Act, We will assess the ability of MHA to meet the needs of the child (for further information on the Rehabilitation Act seek legal counsel and/or go the following website:

Provider Statement

We understand that it is our responsibility to follow MHA’s Decision to Administer Medication Plan and all health and infection control regulations applicable to our program.

We will verify and document the credentials for all new staff certified to administerprescription medications before the staff is allowed to administer prescription medications to any child at MHA. MHA’s Decision to Administer Medication plan will be made available to parents at enrollment, whenever changes are made and upon request.

Facility Name: Mount Hope Academy / Date: February27, 2013
Parent’s Signature: / Date:

Permission to Apply Topical Medication

Mount Hope Academy’s staff has permission to apply First Aid Antibiotic/Pain

Relieving Ointment (Neosporin or Generic Brand) to ______. I

Child’s Name (print)

understand that this medication will help prevent infection and provide temporary relief of pain

or discomfort in minor cuts and scrapes.

______

Parent’s Name (print)

______

Parent’s Signature Date

Permission to Apply Sunscreen

Mount Hope Academy’s staff has permission to apply sunscreen to

______. I understand that suncreen will help protect the skin from

Child’s Name (print)

over exposure to the sun. Please remember to provide us with sunscreen for your child.

______

Parent’s Name (print)

______

Parent’s Signature Date

EMERGENCY EVACUATION PERMISSION SLIP

In the event of an emergency evacuation, Mount Hope Academy has my permission to

transport my child/ren ______using the Academy vans,

(Child’s Name)

staff vehicles, and/or parent vehicles to the following facilities:

Creative Childcare Academy 7001 Harrison Road Fredericksburg, VA 22407 (540) 548-8003

Salem Fields Early Learning Center 11120 Gordon Road Fredericksburg, VA 22407 (540) 786-6292

Minnieland at the Castle

6306 Old Plank Road, Fredericksburg, VA 22407

(540) 786-2434

______You have my permission to transport my child.

______You do not have my permission to transport my child.

______

Please Print Signature Date

Mount Hope Academy

Summer Program Safety Rules

Sunscreen Policy:

Mount Hope will apply sunscreen to your child with your permission. We ask that you provide your own sunscreen because of any allergies your child may have. Please send in sunscreen with the signed permission slip.

Shoe Policy:

Your child’s safety is our number one priority. We ask that you please send your child to summer camp in closed shoes only. We recommend sneakers, tennis or athletic shoes. No sandals or flip-flops permitted except during swimming.

Field Trip Dress Code:

Mount Hope Academy Summer Program T-Shirts must be worn on all field trips. If a child arrives at Mount Hope on the day of a field trip without a Mount Hope T-Shirt, they will not be permitted to attend the field trip.

Mount Hope Academy Summer Program

POOL RULES AND SWIMMING PERMISSION FORM

1. Children are to supply and be responsible for their own suits and towels. Parents are encouraged to label swimsuits and towels.

1. Only one-piece swimsuits and swimming trunks are permitted while swimming.

1. Swimming is permitted only when there is a lifeguard or swimming instructor on duty.

1. No running, pushing, or dunking will be permitted.

1. No gum chewing is permitted in the pool area.

1. No food or drinks are permitted in the pool area.

1. No glass containers are permitted in the pool area.

1. Conduct which may result in self-injury or injury to others will not be permitted, and any children engaging in such activity may be denied swimming privileges.

1. Children are permitted to bring pool toys, e.g. mask, fins, snorkels, etc.

1. Children with open sores, runny noses, and ear infections will not be permitted in the pool.

I have read and understand the above stated pool rules and swimming schedule. I hereby give my permission for ______to participate in free swim held at Wilderness Resorts during Mount Hope Academy’s Summer Program. I agree to review the Pool Rules with my child prior to participation.

Signature of Parent or Guardian______

Date______

My child’s swimming skill level is: ______

Summary of Fees

Registration fee - $50.00, $25.00(if paid before April12th)

Activity fee –3-5 year olds - $85.00

6-12 year olds - $100.00

Tuition- $110.00per week for students who will be picked up on or before

4:00 p.m.

$135.00 per week for students who will also be utilizing

aftercare (4-6:30 p.m.)

*Late pick-up fee - $2.00 per minute per child.

Agreements:

The Academy agrees to notify the parent/guardian/custodian whenever the child becomes ill and the parent agrees to pick the child up within one hour after notification.

The parent/guardian/custodian authorizes the Academy to obtain immediate care if any emergency occurs when he/she cannot be located.

You must choose one of the following when you register your child:

______I am enrolling my child in the summer program as well as the summer after care (4-6:30 p.m.) program. I understand that my weekly fee will be $135.00 ($110.00 plus $25.00 aftercare fee). I also understand that there will be a late fee of $2.00 per minute, per child for pickup after 6:30 p.m. I understand that in order to avoid this fee, I should contact someone on my pick-up list to pick up my child/children.

______I am enrolling my child in the summer program. I will not utilize the summer after care program. I understand that my weekly fee will be $110.00. I also understand that there will be a late fee of $2.00 per minute, per child for pickup after 4:00 p.m. I understand that in order to avoid this fee, I should contact someone on my pick-up list to pick up my child/children.

I understand that I am enrolling my child in aten week summer program. I am responsible for weekly fees beginning June 7, 2013and ending August9, 2013. Tuition is not prorated for holidays or inclement weather. Tuition fees will be lifted for oneweek of vacation if a two weeks written notice is given.

Weekly tuition payments are due in advance by closing on Fridays. Payments received after this time will be assessed a $30 late fee. If an account is not brought up to date within one day after becoming delinquent your child may not return until the delinquent account is brought up to date.

I have read and understand the policies above and would like to enroll my child in the summer program. I have attached the non-refundable registration fee.

SIGNATURES:

Date: ______

Parent/Guardian/Custodian: ______

Administrator: ______

Summer Dress Code:

GIRLS

Acceptable

Girls are permitted to wear skirts, skorts, dresses, and shorts that come no more than 1 ½ inches above the knee.

Sleeveless tops must fit the total width of the shoulders. If leggings are worn, they must be worn with tops that completely cover the bottom. The leggings are not to be excessively tight or see-through.

Tennis shoes or athletic shoes

Unacceptable

Girls are not permitted to wear tank tops, halter tops, spaghetti straps, low cut off the shoulder tops, sheer or see-through tops, blouses that show the mid drift, excessively tight clothing, or clothing imprinted with questionable messages, or symbols, noslip-on shoes, crocs, or sandals.

Acceptable Swimwear

One piece swimwear

Unacceptable Swimwear

Bikinis or two piece swimwear

BOYS

Acceptable

T-Shirts

Other outer shirts

Shorts (should come no more than 1 ½ inches above the knee)

Pants

Athletic pants

If wearing baggy pants or shorts they must be kept pulled up at all times (sagging is not permitted)

Unacceptable

Clothing imprinted with questionable messages, symbols, or pictures

Undershirts worn as outer shirts

Acceptable Swimwear

*Should be modest

Boxer style swim trunks only

Supply List

Paint Shirt

Scissors (blunt end for 3-7 year olds)

Crayons

Markers (broad)

Color pencils (8-12 year olds)

Nap time mat, crib size pillow, and blanket (3-5 year olds)

Complete change of clothes (3-5 year olds)

White Glue

Swimming Supply List

“Wilderness Resort”

9-12 year olds (twice a week) 6-8 year olds (once a week)

“Mount Hope Academy”

3-5 (water play)

Bag for dry clothing, Plastic bag for wet clothing

Towel

Swim shoes or flip flops(to be worn at all times during swim time/water play)

One piece bathing suits (girls)

Swim trunks (boys)

Sunscreen (Sign & return permission form)

*Please remember to label your child’s items.