Newport Salvation Army Day Camp Application: 2016

Newport Salvation Army Day Camp Application: 2016

Enrollment Packet

Summer Enrichment Day Camp 2016

Contact:
Bill Brackett

340 West 10th St, Newport, KY 41071
859-431-1063

Dear Parent,

Thank you for your interest in The Salvation ArmySummer Enrichment Program. We hope your child will be a part of our program. Summer EnrichmentDay Camp is for children entering 1st– 6thgrade only. Our activities and field trips are structured to meet the needs and abilities of children of this age range.

It is important that you understand that getting this packet does not guarantee your child a place in our program. Children may only attend the program after you fill out and return the application packet, along with the $50 registration payment. This payment covers the cost of your child’s t-shirt and the cost of the season pass for the Beach Water Park. This payment is non-refundable. Then each week a $50 enrollment fee per child is due. We request that this be paid the Friday prior to services provided. This totals $400for the entire 8weeks of summer care. (June 6th- July 29th, 7:45 am – 4:30 pm).

 Each child must provide a spray on bottle ofsunscreen. The spray bottle allows staff toprovide propercoverage to your child, with easy hands off application. This sunscreenis kept onsite to beused as needed.

Please feel free to call our staff at(859)-431-1063 if you have any questions.We look forward to spending the summer with your child.

Sincerely,

Captain Misty Simco

Commanding Officer

Child Profile

Student’s Name:______

Home Address:______

Telephone:______

Grade for 2015-2016 school year______

Date of Birth: ______

Departure/Release

Please list designated persons who your child may be released to. These people must be at least 18 years of age.

Name ______Relationship ______

Address ______Phone ______

Name ______Relationship ______

Address ______Phone ______

Name ______Relationship ______

Address ______Phone ______

EMERGENCY CONTACTS

Please list designated people who may be contacted in case of emergency, ifwe are unable to reach you. These people must be at least 18 years or older. (Minimum of two people).

Name ______Relationship ______

Address ______Phone ______

Name ______Relationship______

Address ______Phone ______

Name ______Relationship ______

Address ______Phone ______

*** Reminder***

I understand that my child will only be released fromthe Salvation Army to a parent/guardian or designated person. I understand thatif it be necessary to release my child to one of the designated individuals,proper I.D, will be requested from them attime of pick up. I will also notify the staff of schedule changes that will affect my child’s arrival and departure times.They will not be permitted to walk home.

______

Parent/Guardian Signature Date

Medical Release Form

AUTHORIZATION FOR AGENT TO CONSENT TO THE TREATMENT OF MINOR

I, the undersigned, parent/guardian of ______(minor) do hereby authorize The Salvation Army, as agents for the undersigned to consent to any X-ray, medical examination, anesthetic, medical or surgical diagnosis or treatment or hospital care at the nearest available hospital, which is deemed advisable by and is to be rendered under the general or special supervision of any physician and surgeon licensed by law to practice.This authorization shall remain in effect while the child is enrolled at The Salvation Army. I understand that a conscientious effort will be made to locate the parent(s)/guardian before any action will be taken.

______

Parent/Guardian Signature Date

In case of emergency my preferred hospital for treatment or hospital care is listed below. I am aware that depending on location and situation, alternative hospitals may be the selected by emergency services during an emergency situation.

Hospital Name: ______

Hospital Address: ______

Telephone Number:______

Family Physician/Pediatrician:

Name:______

Address:

______

Telephone Number:______

I understand that my child’s medical information will be shared with the necessary day camp staff members as deemed pertinent and medical professionals contacted in case of medical emergency. I agree to the release of any medical records necessary for treatment, referral, billing, or insurance purposes.This authorization shall remain in effect while the child is enrolled at The Salvation Army. I understand that a conscientious effort will be made to locate the parent(s)/guardian before any action will be taken.

______

Parent/Guardian Signature Date

Child Medical/Physical Care Plan

Child’s Name: ______

Date of Birth: ______

Special Health Concerns:

______

Symptoms to watch for and emergency action to be taken if the following symptoms occur:

______

Activities/Foods/Environment conditions to be avoided:

______

Medical procedures to be followed and expected benefit of treatment:

______

Are any medications required? No ___ Yes ____

If yes, what medications?

______

I give permission for the staff at The Salvation Army Day Camp to perform the procedures in my child’s Medical/Physical Care Plan.

______

Parent/Guardian Signature Date:

Request for Administration of Medication

One form must be completed for each medication. Sunscreen lotion requires the completion of this form as directed by the State of Kentucky. Check all that apply:

__ Prescription Medication __ Topical product/lotion

__ Refrigeration Required__ Food supplement

__ Nonprescription Medication __ Modified diet

Complete the following information:

Name of Child: ______Date of Birth: ______Weight: ______

Name of Medication: ______

Exact Dosage: ______

To be administered at the following times:______

______

Parent/Guardian Signature:

*************************************************************************************

The following information must be completed by a licensed physician, a licensed dentist or an advance practice nurse when:

1) A physician’s instruction is needed for a nonprescription medication (e.g. child is underage or underweight per label instructions); or

2) It is a sample medication without a prescription label; or

3) The nonprescription medication is to be given longer than three consecutive days within a 14 day period or is a topical lotion or product that is being used for a skin ailment and is to be given no longer than 14 days.

4) The child is on a modified diet (an entire food group is eliminated)

5) The medication contains codeine or aspirin

(Name of child) ______is under my care and should receive

(name of medication, vitamin, diet) ______as follows:

(include dosage and instruction) ______

Expiration date: ______

Signature of physician or advanced practice nurse:______

Date of signature: ______Telephone Number:______

Lunch Option

______Eating the breakfast /lunch provided by The Salvation Army

______bringing a packed lunch from home.

***By packing a lunch, the rate for yourchild’s payment will NOT be reduced.***

Please note: If your child has any special dietary requirements a lunch packed from home may be the best option.

T-Shirt Selection

Please circle the size of the t-shirt you would like for your child:

Youth Adult

XS S M L XL XS S M L XL XXL

Children are required to wear these on field trips, or when requested in order to attend.

SWIMMING PERMISSION SLIP

Child’s Name:______

My child is a ______swimmer ______non-swimmer

I grant permission for my childto participate in water activities on and off site.

______

Parent/Guardian Signature Date

Routine Field Trip/Transportation Permission

Each week the children enrolled in Day Campwill participate in a variety of field trips. My child,

______, has mypermission to participate in field trips by walking, car, van or bus (or hired rental bus/driver) with The Salvation Army. During the hours my child is in the care of The Salvation Army, I may be

reached at this telephone number: ______.

______

Parent Signature Date

Permission for Photography/Videotaping

There will be an occasional need to develop photographic and video data to document activities and events taking place during Day Camp. Students will often be featured in this collection. These photographs are often used for PR purposes, such as websites, and other PR publications.

Please Check:

_____ The Salvation Army has my permissionto photograph/videotape my child while participating in activities.

_____ I do not give my permissionto The Salvation Army to photograph/videotape my child while participating in activities.

______

Parent/Guardian Signature Date

Permission for Internet Access

The Day Camp students do have access to the internet. The internet is a worldwide web of computer connections that facilitates the sharing of information. This information resource is literally a microscopic view of all that is presently known to man through the world.This enormous variety of information has its pitfalls. There are areas that remain unrestricted, that contain explicit, uncensored material that could be considered morally corrupt and perverse at best. Close monitoring will be provided during internet use and prior to use students will be advised of words and phrases triggering alarms and those being of potential risk. In the event that students are found to have gained access to inappropriate material, they will be removed from the system for the remainder of the session and that student’s parent/guardian will be notified. The Day Camp staff will take great care to ensure that a responsible representative supervises the computers at all times. However, precautionary measures are not to be confused with guarantees.

_____ My child may haveaccess to the internet.

_____ My child may not haveaccess to the internet.

I understand that the photographs/videotapes may be used inpresentations, posters, brochures, advertisements and other promotional areas on behalf of The Salvation Army. All such photography will be maintained as property of The Salvation Army with all rights reserved.

To parents who authorize internet access:

Your signature below acknowledges that you have discussed with your child that availability of material on the internet, your beliefs, morals, etc. relating to reading/viewing them.

______

Parent/Guardian Signature Date

Behavior Policy

Please support the Day Camp guidelines by reviewing the following expectations with your child:

1.Keep hands and feet to self.

2. Use kind and appropriate language and behavior.

3.Respect and care for the Center, its equipment and materials.

4. Respect all adults and teachers.

5. Respect other children, their space, their property, and their privacy.

Our program utilizes a behavior management program that focuses and rewards positive behavior rather than focusing on and punishing negative behavior.Children will strive throughout the week to earn special privileges and rewards.

______

(Parent’s Signature) (Date)

______

(Child’s Signature) (Date)

Discipline Policy

The Salvation Army staff believes that children learn best through positive reinforcement, and the teaching and modeling of proper behavior. Corporal punishment and harsh verbal discipline is never acceptable in our program. We expect that you will support and respect ourdiscipline policy whenever you are present in our center. To maximize the enjoyment and learning experience whileattending Day Camp, it is necessary to have a fairand consistent discipline policy. It is our desire that your child take advantage of all the activities offered. His/her appropriate and respectful behavior will help to make this possible. A serious disciplinary problem is defined as one in which a child is hampering the smooth flow of the program, by either requiring constant one-on-one attention; is inflicting physical or emotional harm to other children, is physically aggressive towards staff, or is otherwise unable to conform to the rules and guidelines of the Day Camp. The Salvation Army takes a “hands-off” approach, however a “bear hug” hold will be used if a child is in danger of inflicting physical harm to children or staff. If it is necessary to use a restraint of this nature, a discipline incident report form will be completed.

The Newport Salvation Army also uses a checkmark or strike system. This means that the child will be given a warning and if the behavior is repeated they will gain a strike. Once three strikes are reached, the child will be sent home for the rest of the day with no refund for daycamp fees. If the child continues to show this behavior once returning, a longer suspension will be issued. A serious disciplinary problem as defined above can and will result in a “Strike 3” regardless of previous infractions.

When a child displays unacceptable behavior, the following steps will be followed:

1. Reasoning and Redirection to other activities, Warning.

2. Removal from activities for a “break” followed by discussion with a staff member about the behavior, Strike 1.

3. Meeting with parent, child, and staff to develop a behavior plan, Strike 2.

4. Suspension from the program and no refund of fees, Strike 3.

5. Dismissal from the program with no refund of fees.

If a child shows two acts of physical aggression during any one day, the child will be immediately separated from the group and the parent/guardian will be called to pick up the child. Abusive language or actions of parents toward staff, children, or others during Day Camp may result in suspension/dismissal of the child from the program.

I have received,read, and understand this discipline policy______

Parent Signature Date

1