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1 St. Rita School Summer Camp Program Registration Page 1 Please print out this form and complete it in its entirety. Return or mail this registration form AND all required medical forms to: ST. RITA SCHOOL (ATTN: MRS. JONES) 1601 WHITNEY AVENUE, HAMDEN, CT Students Camper/Junior Counselor Information : Student Camper s Name Age: Student Camper s Name Age: Student Camper s Name Age: Junior Counselor s Name Age: Junior Counselor s Name Age: Home Address: Town: State: Zip Code: Home Phone: Parent Information : Primary Emergency Contact Phone Number & Name: 1 st person to contact in an emergency. Mother s Name Cell Number: Mother s Address (if different from camper s home address) Father s Name Cell Number: Father s Address (if different from camper s home address) Summer Camp Week Sign Up Information : Please check the weeks that you are registering for & the camper s or Junior Counselor s age June20 th -June24 th Age(s): June 27 th -July 1 st Age(s): July 2 nd -July 8 th Age(s): July 11 th -July 15 th Ages(s): July 18 th -July 22 nd Age(s): July 25 th -July 29 th Age(s): Aug. 1 st -Aug. 5 th Age(s): Aug. 8 th - Aug. 12 th Age9s):

2 Camp Costs & Fees: ST. RITA SUMMER CAMP REGISTRATION PAGE 2 PLEASE PRINT THIS PAGE OUT, FILL OUT ACCORDING TO YOUR WEEKLY SIGN UP AND RETURN TO ST. RITA ATTN: Mrs. Jones $15.00 supply fee (covers the cost of materials and craft fees) Per student camper ONE TIME FEE for single or multiple week sign up How many student campers are you registering? This fee does not apply to Junior Counselor. $15.00 per student camper A. My TOTAL for supply fees is: 1. $ camp fee (covers registration, activity & full day attendance costs) for a full week attendance, per week. Applies for one camper, attending full day sessions for one week. (Mon-Fri. 8am-3pm) $ non refundable fee (included as part of camp fee / not refunded for cancellations or absences.) 2. $ camp fee (covers registration, activity & full day attendance costs) for a full week attendance, per week regardless of the number of siblings you register. Applies to two or more sibling campers, attending full day sessions for one week. (Mon-Fri. 8am-3pm) $ non refundable fee (included as part of camp fee / not refunded for cancellations or absences.) 3. $ camp fee (covers registration and half day attendance) for one full week of half day attendance, per week. Applies for one camper, attending a half day session for one week. (Mon-Fri. 8am-12pm) $ non refundable fee (included as part of camp fee / not refunded for cancellations or absences.) 4. $ camp fee (covers registration and half day attendance) for one full week of half day attendance, per week. Applies to two or more sibling campers, attending half day sessions for one week. (Mon-Fri. 8am-12pm) $ non refundable fee (included as part of camp fee / not refunded for cancellations or absences.) 5. $ Junior Counselor fee (covers registration for full or half day attendance) per week. $ non refundable fee (included as part of Junior Counselor fee / not refunded for cancellation or absences.) Please note: Registration fees for Campers and Junior Counselors are separate. Based on the number of campers and/or counselors you are registering, which camp fee applies to you? Please circle one for campers OR if you are registering campers and counselors then circle more than one that may apply to you below. I am circling the number(s) that apply to the registration fees associated with the number of students attending summer camp, listed above, that explains camp fee costs. (For example: one camper = circle number 1 / one camper and one junior counselor = circle number 2 three campers = circle number 3 etc.) B. My TOTAL for registration(s) is C. Please add your totals from LINE A and LINE B combined to complete the total for Line C. TOTAL CAMP COSTS INCLUDING SUPPLY FEES (per camper(s)/junior counselors):

3 ST. RITA SCHOOL SUMMER CAMP PROGRAM CAMPER AND JUNIOR COUNSELOR EMERGENCY INFORMATION FORM Please print out and complete one form per camper and/or Junior Counselor. Please be sure to include this information form when mailing in your camp registration form. Student Camper s Name Or Junior Counselor s Name Date of Birth: Age: Home Address: Parent s Primary Parent(s) Name(s): Parent Address: (If different than camper or Junior Counselor s info. as listed above.) Parent s Cell or Main Contact Number: In case of emergency, this would be the first number to be contacted. Please include multiple contact numbers, if applies to more than one parent. Secondary Emergency Contact Name: Please list someone other than a parent. Secondary Contact Cell or Phone Number: If a parent cannot be reached, this would be the next contact to be made. Parental Insurance Information Medical Insurance Policy Name: Medical Insurance Policy #: A copy of the insurance card (front & back) must be included with this form. Camp Coordinator Copy

4 MEDICAL CONSENT FORM ST. RITA SCHOOL SUMMER CAMP PROGRAM MEDICAL INSURANCE INFORMATION: St. Rita School Office Copy All campers and Junior Counselors must be covered by insurance. The following must be completed in order to participate. Medical Insurance Policy Name: Medical Insurance Policy #: A copy of the insurance card (front & back) MUST be included with all registration forms. CONTACT INFORMATION: Father s name Home phone: Work phone: Cell phone: Mother s name: Home phone: Work phone: Cell phone: Emergency Contact: Phone: Should my child sustain or incur any accident or illness while attending St. Rita School Summer Camp, I hereby authorize the Camp Coordinators or any Administration, or agents, to execute any and all documents, including any necessary releases, which might be required by any medical facility to perform any emergency care on my behalf. In the event that my child has an illness or accident during the camp day program, which requires a visit to the doctor or hospital, the existing family policies will solely represent the insurance coverage. I give permission for my child to participate in any and all activities. I give permission for photos and released information related to my child s performance in any aspect of St. Rita School Summer Camp to be used for marketing purposes, including our web site. I acknowledge that my child s participation in the summer camp program activities entails known and anticipated physical activities at an age appropriate manner and injuries could occur. I understand that physical activities are supervised at all times and hereby waive any legal rights to hold legal action against St. Rita School, St. Rita Church or any of its affiliates, agents, administration, counselors and/or camp coordinators. I, the undersigned for myself and as guardian of PRINT IN THE NAME OF STUDENT CAMPER / JUNIOR COUNSELOR understand that summer camp involves active, physical, educational and hand-on activities and hereby acknowledge that my child is physically fit and mentally capable of participating in all activities throughout the day. Signature Date (Parent/Guardian) Print Name

5 MEDICAL, ALLERGY AND INFORMATION FORM ST. RITA SCHOOL SUMMER CAMP Please fill out one Medical, Allergy & Information form per student camper or Junior Counselor. Please return this form with the registration form and the two insurance forms. Student Camper s Name Junior Counselor s Name Date of Birth: Age: 1. Does your child have any food and/or other allergies? Please specify and list any and all food restrictions and/or other medical allergy concerns that Camp Coordinators and Administration should be made aware of. 2. Will you be supplying camp with an EpiPen, Benadryl and/or other medicine(s) that your child will be required to have on site for safety pertaining to food or medical allergies? Please list all and explain. 3. Are there any other medical concerns about your child that are important for Camp Coordinators and Administration to be aware of while your child is in our care? This could include physical limitations, emotional concerns or anything that you feel is important for us to know about when working with your child. 4. Will your child be participating in the Hot Lunch program? YES / NO It is the responsibility of each parent to research and determine if the hot lunch provided is considered food allergy safe for your child s consumption during the camp day. Otherwise, it is recommended that parents provide all lunches, drinks, and snacks for their child each camp day. Lunch menu is posted online weekly.

6 BEFORE AND AFTER HOUR(S) CAMP CARE If you will be using the before and/or after camp hours program weekly registration is required, in order to determine staffing needs. Please read the following information carefully and be sure to understand the guidelines and procedures for the program. Before Camp Care - guidelines & fees (7:30am-8:00am Every day) * Before camp care begins promptly at 7:30am. Please do not drop your child off earlier than 7:30am, as no supervision will be available to watch your child(ren). * the cost for before camp care is $3.00 per day, per child Or $5.00 for two or more siblings. * The before camp program fee needs to be paid daily in cash only. * there is no pre-registration for before camp care. Supervision is available during all camp days beginning promptly at 7:30am. * no electronic devices are allowed in the before camp program for any student campers. * there are no structured activities in the before camp program, just supervised free time until the start of the camp day. * no camper is to bring any food for consumption to the before camp program, as there may be food allergy concerns with other campers also in attendance in the before camp program. After camp care guidelines & fees (3:00-5:00pm by registration only.) * Pre-registration for after camp care is required on the Monday, of the week, after camp care will be needed. Registering your child(ren) after the Monday will not be accepted, as staffing needs will have already been determined for the week. No exceptions please plan accordingly. *. (pre)registration forms, for after camp care, should be turned in with your child (on the Monday of the week care is needed), including the weekly payment in cash or check (made out to St. Rita School). Without weekly payment, after camp care registration for your child is not complete. * Please turn in pre-registration forms and payment in an envelope with your child s name clearly marked on the outside. (Again this payment is turned in on the Monday of the week after camp care is needed.) * parents will need to register and pay separately for each week after camp care is needed. * after camp care runs from 3-5pm every day. * the cost is $15.00 per child or $25.00 for two or more siblings, regardless of time spent in the after camp care program. * please provide a snack and a drink for your child s stay in the after camp program. *. no electronic devices are allowed for student campers in the after camp care program. * there is a $15.00 late fee per child for any student camper that is picked up after 5:00pm. Every 10 minutes after 5pm, another $15.00 late fee will be added per child. Please be prompt in your pick up. We must adhere to the availability of the school grounds, during summer hours.

7 After camp care registration form Please be sure to turn this form in on the Monday of the week that After Camp care is needed for your child(ren). Staffing for After Camp care is determined based on these forms being sent in at the beginning of the week. NO LATE REGISTRATION FORMS FOR AFTER CAMP CARE WILL BE ACCEPTED EVEN IF YOUR CHILD IS ABSENT ON MONDAY. We kindly ask that you make arrangements in advance to have someone else turn this form in for you. The only exception is the week of the July 4 th Holiday During this week, all After Camp care forms should be turned in on Tuesday, July 5 th. Parents will need to turn in one form per week for your child(ren) s registration. Parents should send in this form, with their After Camp care payment on the Monday, of the week that care is needed. Only then is registration complete. $15.00 per child or $25.00 for two or more siblings. This is the daily cost for After Camp care. Cash or checks are accepted forms of payment. Make checks payable to: St. Rita School. List all names of student campers, who will be attending, below. Student Camper s Name Student Camper s Name Student Camper s Name Student Camper s Name Junior Counselor s Name Week of: Monday dtuesday Wednesday sthursday Friday Check off the days that After Camp care is needed and for how many children on each day. COST: $15.00 per day per child / $25.00 per day for two or more siblings TOTAL WEEKLY COST: Please add your weekly cost and make checks payable to St. Rita School. When this weekly registration form and payment are made, only then is your child s registration complete for the After Camp care program. Thank you, in advance, for your cooperation. A $15.00 late fee PER CHILD will be applied for any student camper that is picked up after 5pm. Every ten minutes after 5pm, another $15.00 late fee will be applied, PER CHILD. Please be prompt in your child s pick up. We need to adhere to the availability of the school grounds during the summer months. Thank you, in advance, for your cooperation with this policy.

8 CHECK LIST FOR ST. RITA SUMMER CAMP REGISTRTION PROCESS 1. Print out Registration Page 1 and complete according to the number of student campers or junior counselors you will be registering for the summer camp program. Be sure to check off the weeks each student camper and/or junior counselor will be attending and their ages. Be sure to also complete the Parent Information section. This page will need to be completed and returned or mailed to St. Rita School Attn: Mrs. Jones 2. Print out Registration Page 2 and complete the camp fees and cost (LINES A,B & C) and calculate your weekly total for the amount of campers and/or junior counselors you are registering. This page will need to be completed and returned or mailed to St. Rita School Attn: Mrs. Jones 3. Print out Camper & Junior Counselor Emergency Information Form (Camp Coordinator Copy). These emergency forms stay with your child s head counselor throughout the entire camp day. Because not all campers are in the same age groups, it is necessary that we have one of these forms for each student camper and junior counselor. Please be sure to include a copy (front and back) of your insurance card with this paper. (One copy needed per family.) This page (one per student camper and junior counselor) will need to be completed and returned or mailed to St. Rita School Attn: Mrs. Jones 4. Print out the Medical Consent Form (St. Rita School Office Copy) Complete this and parent s must sign at the bottom. Without this form, no registration for any student camper or junior counselor is complete. This form needs to be completed for each student camper and/or junior counselor. (One per student camper and one per junior counselor.) If you included a copy of your family s medical card for #3 it is not necessary to include another copy for #4. We will keep all information on file for your child during their stay at summer camp. This page needs to be printed out, signed and returned or mailed to St. Rita School Attn: Mrs. Jones (One of these forms needs to be completed for each student camper and/or junior counselor.) 5. Print out Medical, Allergy & Information Form One of these forms needs to be completed for each student camper and/or junior counselor. Please be sure you are specific in any food or seasonal allergy or other medical information that is important and pertains to the health or well-being of your child. Epi-Pens and or other medicines, inhalers etc. will need to be provided by parents and brought in and kept on campus throughout the week your child is present at camp. All medicines, inhalers, Epi-Pens can be picked up at the week s end by parents. It is the parent s responsibility to provide these for summer camp use and to pick them up when your child s camp week is complete. This page (one per student camper and junior counselor) will needs to be completed and returned or mailed to St. Rita School Attn: Mrs. Jones 6. Print out the weekly After Camp Care Registration Form and complete it according to the needs of your child for each week. Please be sure to include the names of all Student Campers and or Junior Counselors who will be staying for the extended day and determine your individual costs based on your needs. This page needs to be printed out and completed and is ONLY accepted on the Monday of the week that after camp care is needed. NO LATE REGISTRATION FOR AFTER CAMP CARE WILL BE ACCEPTED. Due to staffing needs we cannot make exceptions to this rule. Please be timely in turning in this document on the Monday of each camp week. The only exception is the week of the July 4 th holiday After Camp Care Registration is due on Tues. July 5 th for that week ONLY. NOTE: REGARDING HOT LUNCH PROGRAM FOR FULL DAY CAMPERS: The weekly lunch menu will be posted on the school website (strita.org) Similar to how lunch is ordered during the school year Parents should sign up and pay for hot lunch through the St. Rita Hot Lunch Portal. Only the summer camp lunch menu will be posted online. If you have a question or concern about the hot lunch ordering program, please inquire with a camp coordinator directly. Thank you kindly. CAMP COORDEINATORS: Mrs. Melissa Jones mjones.stritaschool@gmail.com / Ms. Kayla Sharkey ksharkey.stritaschool@gmail.com

Preregistration for camp is required. Please notify STRIVE of any scheduling changes one full day (24 hours) in advance.

Preregistration for camp is required. Please notify STRIVE of any scheduling changes one full day (24 hours) in advance. 1 Camper Application and Registration Forms Camp STRIVE provides tween, teens and young adults, ages 11-24, with a supportive, safe, and active program during school vacations and throughout the summer.