2018 Summer Day Camp Registration Form

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1 2018 Summer Day Camp Registration Form Camper s Name: Nickname: Male or Female (Circle One) Birth : Age: Parent/Guardian s Name: Address: Day Time Phone: Cell Phone: Address: T-Shirt Selection: (Please check the appropriate box) Youth Small Adult Small Adult X-Large Youth Medium Adult Medium Youth Large Adult Large Medical Information List any known medical conditions that may limit your child from participating in camp: _ List any medications being prescribed by your physician to treat any known medical conditions: List any known allergies that may limit or restrict your child from participating in camp: _ If your child has a disability & requires an accommodation in order to participate, please explain:

2 Release Form Authorization of Treatment: I hereby give my permission to the medical personnel selected by the camp director to order treatment and necessary transportation for my child. Parents must submit a completed Farmville Recreational Medical Form prior to the first day of camp. (See Page 1) Release Statement: I acknowledge that there are natural hazards associated with camp and related activities in an indoor/outdoor setting. I hereby affirm that my child is in good health and physically capable of performing the required activities of camp. In consideration of the Farmville Recreation Department accepting my child and to the extent permitted and provided by State Law, I hereby release and forever discharge the Town of Farmville, its units, agents, and employees from all claim of liability for any damages or injuries which may be sustained while my child is at camp. Photo Release: I hereby give my permission for my child s picture to be used by the Farmville Recreation Department for publication, video, or promotional materials. Water Activities: I understand that some of the camps with the Farmville Recreation Department will include activities in or near water. I give my permission for my child to participate in all water activities included in the camps. For camps that include canoeing, campers must be able to swim. Travel: I give my permission for my child to travel in the Recreation Bus throughout the camp and on occasional field trip destinations in correlation to camp themes. I understand that I will be informed of the field trips scheduled for the week of camp, on the first day of camp. Note: By initialing above, you acknowledge that you have read and agree to the terms and policies. Release of Minors: (Please list all persons who are allowed to pick up your child) Parent/Guardian Signature 2

3 Camper Code of Conduct In order to maintain a safe, fun and productive camp environment, we require parents and campers to read and understand the importance of abiding by the following code of conduct: I will follow the camp schedule. I will respect the counselors, directors, and other campers. I will not use foul language. I will not resort to name calling when an incident occurs. Fighting, hitting or bullying will not be tolerated. I will follow all safety rules set forth by the camp staff. Town of Farmville Summer Day Camp Disciplinary Policy Summer camp is meant to be a fun, educational, and a recreational activity. For the benefit of all campers, it is important that children behave appropriately during the summer day camp. If it becomes necessary to take disciplinary action against a camper, the steps will be followed as outlined below: 1. The camper will receive a verbal warning and an explanation as to why the behavior is inappropriate (whenever possible, this will be done in a secluded setting, away from other campers). The camper s parents will be notified of their behavior when they arrive to pick up their child. 2. Staff will determine the appropriate consequence for the camper s behavior (examples may include a time out or exclusion from participating in an activity). The camper s parents will be notified of their behavior when they arrive to pick up the child. 3. The parents will be called and the child will be excused from all camp programs without a refund of fees. The Summer Camp Staff of the Farmville Recreation Department reserves the right to ban any child from summer camps following a first incident in cases of serious inappropriate behavior. Camper s Signature I agree to help my child abide by the code of conduct. Parent/Guardian Signature 3

4 Farmville Recreation Day Camp Rules & Policies 1. Campers must follow Farmville Recreation Department s Camper Code of Conduct. Please inform your child of these policies prior to the start of camp. 2. All campers must have a completed registration form and medical information form on file by the first day of camp. No camper will be allowed to start participating in camp until a form as been filled out and filed with the Recreation Department. (See Page 1) 3. Campers, for their own safety, should wear comfortable clothing suitable for outdoor activities. No sandals or open toed shoes except on the pool deck are allowed. If proper footwear is not worn, the parent will be notified and asked to bring proper footwear for their child or the child will be sent home. 4. Medication: Farmville Recreation Department staff is not permitted to accept or dispense medication of any kind (except in the event of an emergency) unless a dispense medication form has been filled out by a parent or guardian. It will be the responsibility of the parent/guardian to administer medication to their child. 5. Lunch: If a camper chooses not to eat the lunch that is provided, please send a nonperishable lunch with a drink to camp every day. Mark the lunch box/bag with the child s name. Camp counselors will need to inspect the lunch when it is brought in. 6. Water: The weather during camp is usually very hot. Drinking fountains are available, but we suggest you send extra bottles of water to camp with your child labeled clearly with the child s name. Hint: Freezing a bottle of water with a squirt top allows for cold water for your child as the ice melts. 7. Swimming: During the Summer Camp Program, campers will be allowed to swim at different swimming areas. Proper swim attire is required and it is suggested that it be provided every day. Please, no leotards, shorts with zippers or belt loops, etc. Label swim bags and towels clearly with the child s name. We recommend you send sunscreen on a daily basis and instruct your child on how to apply sunscreen prior to attending camp. Each camper will be required to take a swim test before water related activities. If your child CANNOT swim or has any difficulty swimming at all, please send him/her with a life jacket or float(ies) to camp every day. 8. Programs are limited to registered participants only; visitors or guests will not be permitted. 9. Drop Off/Pick Up: Pick up and drop off location is at the Firemen s Sports Arena (1328 Zion Hill Rd. Farmville, VA 23901) Parents should be punctual in dropping off and picking up campers. All campers must be signed in before entering camp and signed out before leaving. The camp day begins at 9:00 a.m. and ends at 4:00 p.m. Staff supervision begins at 7:30 a.m. and ends at 5:30 p.m. Campers are not allowed to be dropped off any earlier than 7:30 a.m. and/or picked up any later than 5:30 p.m. It is essential that campers be picked up on time from camp; if not picked up by 5:30 p.m., fees and penalties may apply at the discretion of the Camp Director. Please notify the Recreation Department if your child will be dropped off later or picked up earlier than the designated times. Parent/Guardian Signature 4

5 Camp Fees Please indicate camps attending by checking the appropriate boxes: (Children attending Extreme Outdoor Adventure must be 8 years or older) Sports Extravaganza (June 4-7) Artful Antics (July 9-12) Survivor (June 11-14) Mad Science (July 16-19) First Responders (June 18-21) Summer Olympics (July 23-26) Pathfinders (June 25-28) Extreme Outdoor Adventure (July 30-August 2) Deposits are non-refundable. If you are not paying in full, camp fees must be paid by the Wednesday prior to the camp in which the child is registered. If you are only making a deposit you will need to fill out the payment plan contract (can be found on the last page of the registration packet). Must register for a minimum of three camps to qualify for payment plan. Please note that there is an increased registration fee and deposit for Extreme Outdoor Adventure Camp. All other camps are the same amount. Deposit is included in full camp week price. Full Camp Week: $ x Number of Weeks Farmville Resident OR Sibling Discount: $ x Number of Weeks Farmville Resident AND Sibling Discount: $75.00 x Number of Weeks Deposit: $25.00 x Number of Weeks Outdoor Adventure Camp: $ x Number of Weeks Farmville OR Sibling Discount: $ x Number of Weeks Farmville Resident AND Sibling Discount: $ x Number of Weeks Deposit for Outdoor Adventure: $50.00 x Number of Weeks Total Camp Fee: $ For Office Use Only: Cash: Check #: Amount Paid: : INT: **Completed registration forms may be mailed in or dropped off at the Town of Farmville Treasurer s office. A 2.5% transaction fee will be charged if paying in person with a debit/credit card, a 3% transaction fee if paying over the phone with a debit/credit card. Please make checks payable to the Town of Farmville. Mail to: Town of Farmville Attn: Recreation Department P.O. Drawer 368 Farmville, VA

6 Payment Plan Contract I,, agree to make payments on the specified dates and the agreed amounts stated on the payment schedule below to the Town of Farmville. I understand the consequences that will be brought against me if the contract is violated. I agree to pay my balance in full. Camper s Name: Beginning Balance: Camp Week Due Received Payment Amount Balance 1. Sports Extravaganza Wed. May, 30 th 2. Survivor Wed. June 6 th 3. First Responders Wed. June 13 th 4. Pathfinders Wed. June 20 th 5. Artful Antics Thurs. July 6 th 6. Mad Science Wed. July 11 th 7. Summer Olympics Wed. July 18 th 8. Extreme Outdoor Adventure Wed. July 25 th **I agree that the above schedule of payments is an acceptable resolution to help retire my debt with the Town of Farmville. Town of Farmville Payee 6

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