South Shore Stars 2015 Summer Camp and Fall Enrollment

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1 My child is in the grade, and attends After School Program. South Shore Stars 2015 Summer Camp and Fall Enrollment Child s Name(s) Parent s/guardian s Name Home Phone Work Phone Address Your child s school and grade in September, 2015 Please check and initial ALL that apply: I would like my child enrolled in Stars Summer Camp I would like my child to be enrolled in the Before School Program (FALL) I would like my child enrolled in the After School Program (FALL) My child will be leaving as of and will no longer need care. We will not refund for sessions chosen but not used. Exceptions will be made for medical reasons supported by physician s note. It is very important to check and initial ALL sessions that your child will attend. Session # 1: July 6 th -July 17th Session # 3 Aug 3 rd Aug 14 th Session # 2 July 20 th - July 31st Session # 4 Aug 17 th Aug 28 th Payments for sessions 1& 2 are due by 7/15. Payments for sessions 3 & 4 are due by 8/15 If your child is attending camp and you are requesting extended care hours, please choose from the following sites: (extended care 4:30-6:00 PM, 6:15 in Randolph) (Please check one) Quincy Atlantic Randolph St. Mary s Weymouth Please note that all previous balances must be paid in full before camp begins. Sessions, groups, extended care and transportation choices are available on a first come first serve basis. A one week non-refundable deposit is due with this agreement (to be applied to last week s camp fee) 1 st child: Total # of sessions chosen ( ) x $ per session = $ 2 nd child: Total # of sessions chosen ( ) x $ per session = $ * Please add $90.00 per session per child for transportation = $ *Please add $60.00 per session per child for After Camp ( If chosen) Total due = $ Amount Enclosed: MC/Visa # Check # Expiration Date: Parent s/guardian s Signature Date

2 South Shore Stars At Hale Reservation 2015 Health History, Emergency Contact, and Release Form 80 Carby Street, Westwood, MA Tel (781) Fax (781) Male Female Camper or Staff Name (First) (Last) (Middle) Birth Date (Circle One) Street City/Town State Zip Parent or Guardian Information Parent or Guardian Parent or Guardian Address (Only if different from address above) Address (Only if different from address above) Phone Work Phone Work Cell Phone Cell Phone Please list at least one emergency contact that, if necessary, could provide transportation home. Emergency Contact Address Emergency Contact Address Phone Work Phone Work Cell Phone Cell Phone Allergies Penicillin Seasonal Foods Insect Bites Other Drugs Other Please explain reaction and severity: Medications for above allergies: If medications will be administered at camp for above allergies a Medication Information Form must be completed Medications Will your child (or staff member) be bringing any medications (including over the counter medications) to camp? Yes (check one) No If Yes, please complete a Medication Information Form. Please check which of the following may be administered to your child if needed (administered by the Wellness Center): Tylenol Advil Benadryl Nasal Decongestant Cough Drops External Antibiotic Cream Anti-Itch Cream Sunscreen Antacid Insect Repellant with Deet Calamine Sudafed ALL of the above NONE of the above Immunization History: This Massachusetts is a two sided requires document. a Certificate Please complete of Immunization and sign for reverse side. all campers and staff. You may use the form provided or a copy from your doctor s office. Check if attached

3 Does your child (or staff member) have Asthma? Relevant Past Medical History, General Information, and Restrictions Will your child (or staff member) be taking an Inhaler or other medication to camp? Yes (check one) No If Yes a Medication Information Form must be completed Any physical, mental, or psychological conditions requiring medication, treatment, or restrictions while at camp? Does your child or (staff member) take any prescription or over-the-counter medication at home? List any past medical treatment or recent injuries: Describe any specific activities from which your child (or staff member) should be exempted: Any dietary modifications or restrictions? Physician Information: Name of family physician: Address of family physician: Phone: Date of last physical exam: Insurance Information: Insurance Carrier: Insurance Policy Holder Name: Policy of Group #: Authorizations: Accuracy of Information: This health history is correct so far as I know and the person herein described has permission to engage in all camp activities except as noted. Photo Release: I authorize Hale Reservation, American Camp Association, and South Shore Stars to have my child s (or staff members) photo to appear in camp brochures, videos, on websites or other promotional literature. Authorization for Treatment: In case of an emergency, I authorize Hale Reservation and South Shore Stars to administer first aid and to transport my child or (staff member) to the nearest hospital emergency room and to order X-rays; routine tests and treatment; and to release any records necessary for insurance purposes. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director, or his/her designee, to secure and administer treatment, including hospitalization, for the person named above. This form can be photocopied for camp trips. Acknowledgment of Risk and Waiver: I understand and acknowledge my camper (or staff member) may participate in a variety of activities including; swimming, boating, outdoor games, sports, rope course, and other rigorous physical activities. I hereby release and discharge, and agree to indemnify and hold harmless Hale Reservation and South Shore Stars and its officers, directors, members, agents, employees, volunteers, and any other persons or entities on its behalf, against all claims, demands, and causes of actions whatsoever, either in law or equity, relating to or arising from any participation, medical treatment, recommendation, transportation or administration, or any lack thereof. Signature of Parent/Guardian of Camper, Staff Member, or Parent/Guardian of Staff Member under 18 years of Age Date

4 Camper or Staff Name Birth Date 2015 South Shore Stars at Hale Reservation Camper Medication, EpiPen, and Inhaler Administration To be completed for any or all medications that will be brought to and administered at camp. Please Read: Prescribed medications must include the pharmacy label with the Rx number, the name of the medication, dosage, directions for use, and the child or staff s name. Non-prescription medications must be in its original containers, clearly labeled with the child s r staff s name and directions for use. All medications must be kept in the Health Center. Please completely complete the following information regarding the appropriate times and dosages of each medication your child or staff will receive at Hale (attach additional forms if needed). Please sign at the bottom of the page. Name of Medication (if Inhaler or EpiPen complete below as well): Why is this medication taken? Days Taken (please circle) M T W Th F As needed Times Taken (be specific) AM PM Other Dosage Are there any additional notes or instructions for this medication? Name of Medication (if Inhaler or EpiPen complete below as well): Why is this medication taken? Days Taken (please circle) M T W Th F As needed Times Taken (be specific) AM PM Other Dosage Are there any additional notes or instructions for this medication? Type of Inhaler: Location of Inhaler at camp (circle one) Health center or designated secure storage on campers person with camp counselor Who can administer inhaler? (circle one) Qualified Personal Camper Type of EpiPen : Location of EpiPen at camp (circle one) Health center or designated secure storage on campers person with camp counselor Who can administer EpiPen? (circle one) Qualified Personal Camper I hereby give permission for Hale Reservation to administer the following medications to my child or staff member under eighteen years of age during his or her camp attendance. Parent/Guardian Signature Date:

5 South Shore Day Camp 2015 Transportation Information These are TENTATIVE routes based on last year and this year s projections. Final routes will be sent in mid June. Changes may be 15 minutes per stop but you can switch to another stop on your route. After the first week of camp times should remain consistent. Bus monitors are instructed not to leave a stop until the designated time. It is our policy not to drop a child off at a stop without a parent to meet them unless we have written permission. If you would like to have your child left off alone at a stop please indicate on the attached form. Without written permission, we will not drop a child off unattended at his/her stop. We cannot have vehicles waiting at the stop for late parents. Your child will be driven to the nearest Stars Extended Care Location where staff will attempt to reach an emergency contact. Parents will be charged a late fee of $25.00 if this occurs. Buses leave camp at 4:00 PM. Drop-offs begin at approximately 4:30 and finish at approximately 5:30 PM. Drop-off times should remain consistent after the first week, depending on traffic problems.

6 South Shore Day Camp 2015 Transportation Child s Name: Bus Pick-up (AM): (select choices from next page) First Choice: Second Choice: Bus # Pick-up Time in AM Stop Name *You must have a second choice. Please be sure that it is a different Bus # than the first choice. Bus Drop-off (PM): (please check one) I will meet my child at his/her pick-up site. I will meet my child at a different location (same Bus#). I give permission for my child to walk home unattended from his/her pick-up site. I would like my child dropped off at the Extended Care Site chosen. (select below) Check if applicable: Quincy Atlantic Randolph St. Mary s Weymouth Extended Care Site (from 4:30-6:00pm in Weymouth and Quincy, 6:15 in Randolph) I give my permission for my child to be released from the program at the end of the day as described above, and/or to the following people. These people will also be contacted in an emergency, in the order listed, in the event parents or guardians can not be contacted. Name: Relationship: Address: Telephone #: Name: Relationship: Address: Telephone #: Name: Relationship: Address: Telephone #: Any other transportation or release requests must be stated in writing and maintained in the child s file. Your child will not be released to anyone not listed on this form without prior consent, preferably written. In the event that a parent can not be reached to confirm permission of an unauthorized person to pick up a child, staff may try to obtain permission from emergency contacts listed above. Parent s Signature Date

7 South Shore Day Camp TENTATIVE Transportation Routes (Based on last year's enrollment) FINAL TRANSPORTATION ROUTES WILL BE MAILED OUT IN JUNE. QUINCY BUS #1 QUINCY BUS #2 AM Pick-up PM Drop-off AM Pick-up PM Drop-off 7:30 Quincy High School 4;50 7:45 Parker School 4:55 7:45 Lincoln Hancock School 4:40 7:55 Bernazani School 4:40 Quincy Atlantic After Camp PM only 5;00 Quincy Atlantic After Camp PM only 5:00 Union Congregational Church Union Congregational Church 135 Rawson Rd. (617) Rawson Rd. (617) After Camp closes at 6:00pm After Camp closes at 6:00pm WEYMOUTH BUS #3 Weymouth BUS #4 AM Pick-up PM Drop-off AM Pick-up PM Drop-off 7:30 Abigail Adams 5:05 7:30 Seach 4:55 7:40 Pingree School 5:00 7:45 Weymouth High School 4:45 7:55 Joseph Fern Court/Lake Street 4:45 7:55 Nash School No PM Stop Weymouth After Camp PM only Weymouth After Camp PM only 200 Middle Street (781) : Middle Street (781) :05 After camp closes at 6:00pm After camp closes at 6:00pm RANDOLPH BUS #5 AM Pick-up PM Drop-off 7:30 Martin Young 5:05 7:40 Randolph High School 4:55 7:45 St Mary's School 4:50 St. Mary's After Camp 30 Seton Way :40 After Camp closes at 6:15pm 7:55 Donovan School 4:40 You can switch to another stop on your route. A phone call is not necessary but please tell the bus monitor. Please allow 10 minutes on either side of the pick-up and drop-off times for the first week of camp. The times should stay relatively consistent after that depending on traffic.

8 South Shore Day Camp 2015 Swim Form and Field Trips Dear Parents/Guardians: Annually, at no extra cost to you, South Shore Day Camp offers swimming and swim lessons. Our lessons are given by Red Cross Certified Instructors. Participation in our swim program is strongly encouraged. We have created incentives for campers who demonstrate improvement, move up swim levels, and pass the deep end test. Please discuss this option with your child as we will not force participation in this activity. Thank you, Camp Director Child s Name: Age: (please print) SWIM Please indicate below if you want your child to participate in the swim instruction: Yes I give permission for my child to participate in swim instruction No I do not give permission for my child to participate in swim instruction FIELD TRIPS Throughout the summer we provide a variety of field trips which may include going to: the zoo, museums, sporting events or roller skating. If you want your child to be able to participate in field trips, please indicate below: Yes I give permission for my child to go on field trips No I do not give permission for my child to go on field trips Parent s Signature: Date: