Tiger CAMPus REC WELCOME CAMPERS!

Tiger CAMPus REC WELCOME CAMPERS! We are very excited that yu will be jining us this summer in this fun filled active yet educatinal fitness adventure. Our gal is t prvide the highest quality recreatinal day camps. We strive t prvide develpmental and apprpriate activities that prmte life-lng learning f recreatinal and sprt skills t children ages 5-14 years ld. The skills are experienced in a recreatin setting t encurage each child t explre fun and diverse activities. ~ 1 ~

TIGER CAMPus REC SUMMER DAY CAMP 2019 NEW CAMPER REGISTRATION PACKET ~ 2 ~

TIGER CAMPus REC SUMMER DAY CAMP Registratin & Authrizatin Frm (ne per family) Open Huse May 31 st (630pm) Sessin 1 June 3 rd -7 th Sessin 2 June 10 th - 14 th Sessin 3 June 17 th - 21 st Sessin 4 June 24 th - June 28 th Sessin 5 July 1 st -July 5 th (NO CAMP ON JULY 4 th ) Sessin 6 July 8 th -July 12 th Sessin 7 July 15 th -July 19 th Sessin 8 July 22 nd -July 26 th Parent/ Guardian Infrmatin (Name, Phne Number, Email) Camper Infrmatin (Name(s), Age, Birth date, Gender, Address, Shirt Size, Grade) Pick up Authrizatin (Names, Phne Numbers) Learn t Swim Authrizatin Wavier Frm (ne per camper) Child s Name Parent Name Parent Signature Behavir Frm (ne per family) Child(ren) s Name Parent Name Parent Signature Emergency & Medical Infrmatin (ne per camper) Camper Infrmatin (Name) Emergency Cntact Infrmatin (Names), Addresses), Phne Numbers) Physician & Health Insurance Infrmatin (Name, Address, Cmpany, Plicy Number) Parent Signature Medical Infrmatin (Allergies, Health Cnditins, Daily Medicatins, Tetanus Sht, Date f last Physical Exam) Cpy f Immunizatin Recrd ADDITIONAL REQUIREMENTS: Child Medical/ Physical Care Plan (ne per camper, if needed) Request fr Administratin f Medicatin (ne per medicatin, if needed) Authrizatin fr use f image frm (ne per camper) Payment Optins Cash, Credit Cards, Check/Mney Order (Payable t Texas Suthern Dept. f Campus Recreatin) Tiger Camp 2019 will NOT have accept depsits. All sessins must be paid in full. ~ 3 ~

TIGER CAMPus REC SUMMER DAY CAMP Registratin & Pick up Authrizatin Parent/Guardian #1 please Print legibly. First Name: Last Name: Hme Address: City: State: Zip Daytime Address (i.e. wrk): City: State: Zip: Hme Phne: Daytime Phne: Other Phne: Email Address: Parent/Guardian #2 First Name: Last Name: Hme Address: City: State: Zip Daytime Address (i.e. wrk): City: State: Zip: Hme Phne: Daytime Phne: Other Phne: Email Address: Referral Were yu referred by a Returning Camper? Yes By whm? Did yu refer a new camper(s)? (Maximum 3 referrals) Yes Name(s) f camper(s):,, ~ 4 ~

Camper #1 First Name: Last Name: Hme Address: City: State: Zip Birth date: / / Age as f 6/1/19: T-shirt Size: Female Male Camper #2 First Name: Last Name: Hme Address: City: State: Zip Birth date: / / Age as f 6/1/19: T-shirt Size: Female Male Camper #3 First Name: Last Name: Hme Address: City: State: Zip Birth date: / / Age as f 6/1/19: T-shirt Size: Female Male Camper #4 First Name: Last Name: Hme Address: City: State: Zip Birth date: / / Age as f 6/1/19: T-shirt Size: Female Male ~ 5 ~

In each crrespnding bx, write the number f campers that will attend each sessin and the ttal amunt per week. Week REGISTRATION Field Trip Sessin 1: 6/3-6/7 Urban Air $ Ttal amunt per week Student Fee $80 = 1 st child $70 = additinal Staff Fee $100 = 1 st child $90 = additinal Alumni Fee $110 = 1 st child $95 = additinal Cmmunity Fee $120 = 1 st child $100 = additinal Sessin 2: 6/10-6/14 Fun City Sk8 $ Sessin 3: 6/17-6/21 Mvies- Ty $ Stry Sessin 4: 6/24-6/28 REC-Birthday Party $ Sessin 5: 7/1-7/5 Typhn Texas $ Sessin 6: 7/8-7/12 ITZ USA $ Sessin 7: 7/15-7/19 Sessin 8: 7/22-7/26 Mvies Lin King REC- Birthday Party $ $ Ttal Amunt: $ Methd f payment: Cash Check Mney Order Debit/Credit Card **** Please nte: t receive Student Rate, applicant must meet the fllwing requirements: - Enrlled in Summer I r II 2019 semester as a TSU student OR have cmpleted the spring 2019 semester as a TSU Student. - Enrlled in undergraduate, pst-bac r graduate prgram (PHD candidates are nt eligible) **** Payrll Deductin Requirements: - Must be a full time emplyee f Texas Suthern University at the time f enrllment - Payrll deductin frms must be received by May 15 th fr apprved enrllment payment. ~ 6 ~

Learn t Swim Prgram Campers have the ptin t pt ut f the Learn t Swim Prgram (Nte: althugh we encurage all campers t take advantage f ur well-structured learn t swim prgram we understand ther factrs may play a rle t prevent that frm ccurring). If yu check YES, yur camper will be added t the learn t swim prgram and will participate in the daily swim activities ffered. If yu check NO, yur camper will be placed in a daily reading based educatin sessin that will require daily written assignments. If yu decide t change yur mind, and pt back in, yur camper will begin L-T-S sessins the fllwing week. LEARN TO SWIM PROGRAM Please check the apprpriate bx belw: YES My camper(s) WILL participate in the learn t swim prgram. NO My camper(s) WILL NOT participate in the learn t swim prgram. I understand that if I pt my camper OUT f the prgram they will be required t attend a daily reading based educatin sessin during their swim perid. Please nte: if campers are cnsistently missing prlnged swim sessins the camp administratin will have full authrity t remve the camper frm the L-T-S prgram and place them in the alternative educatin sessin. Parent Signature: Date: ~ 7 ~

Camper Pick up Authrizatin My child shuld be kept at the Summer Day Camp until he/she is picked up AND signed ut by ne f the parents/guardians r ther designated individual listed belw. I understand that the persn picking up my child, will be asked t shw a gvernment issued pht ID (driver s license, ID card, current Passprt, etc.). Parent must list themselves in additin t any ther authrized individual. Only thse listed belw will be permitted t pick up my child. I understand that Campus Recreatin Summer Day Camp staff will nt release my child t anyne nt listed, regardless f relatinship t child. If specific individuals are nt permitted t pick up my child, I must attach apprpriate dcumentatin. 1. Phne 2. Phne 3. Phne 4. Phne 5. Phne 6. Phne ~ 8 ~

Field Trip Permissin Slip I will cmplete the attached permissin frm fr my child t attend the field trips planned fr the week that he/she attends the TIGER CAMPus REC SUMMER DAY CAMP thrugh the Campus Recreatin Department. I understand the children will be traveling by ft acrss campus t ther indr r utdr areas lcated arund the TSU Campus, as well as by University prvided vehicle t special ff campus trips ffered during each sessin The fllwing is a list f ff campus field trips that my child may attend: Hustn Z Hustn Space Center Tur the Tyta Center Parent/Guardian Signature: Date: ~ 9 ~

RELEASE AND WAIVER OF LIABILITY I give permissin fr my child t participate in this camp at facilities wned and perated by TSU. I acknwledge and accept that the camp may expse my child t hazards and risks, including injury r death, and that TSU cannt cntrl these risks. I acknwledge there be physically strenuus activities and certify that my child is fit and capable f such participatin. I understand that TSU is nt respnsible fr any medical expenses assciated with any persnal injury my child may sustain and understand that TSU des nt prvide medical insurance fr me and my child. I certify that my child is cvered by adequate insurance t cver any persnal injury which he may sustain while participating in this camp. In cnsideratin f TSU prviding the pprtunity fr my child t participate in this camp, I release TSU, its Bard f Regents, fficers, emplyees, and representatives frm any and all liability t me and my child, ur persnal representatives, estate, heirs, and assigns fr any and all claims, demands and causes f actin fr any and all illness r injury t my child, including death arising ut f, during, r in any way cnnected with this camp. I agree t indemnify and hld harmless, waive and cvenant nt t sue TSU, its Bard f Regents, fficers, emplyees, and representatives frm liability fr the injury r death f any persn (s) r damages t prperty that may result frm my child negligent f intentinal act r missin while participating in the camp. I hereby authrize the staff f this camp t act fr me accrding t their best judgment in any emergency requiring medical attentin. I authrize and give cnsent fr TSU t administer general first aid fr any minr injuries r illnesses experienced by my child. If my child is in need f emergency medical care and TSU is nt able t reach me r the emergency cntact, I authrize TSU t sign all necessary papers and arrange fr emergency treatment and hspital care. I am the parent r legal guardian f the minr, and I am signing n behalf f said minr. Printed Name f Parent/Guardian Signature f Parent/Guardian Hme phne Wrk Cell phne Date ~ 10 ~

Behavir Expectatins The TIGER CAMPus REC Summer Day Camp Staff and Administratin prvides children with guidelines fr apprpriate behavir and rules t fllw while enrlled at camp. We encurage psitive actins thrugh psitive reinfrcement and clse supervisin. Our main gal is t keep the children safely invlved in activities s the inapprpriate behavir is limited. The fllwing steps shall be fllwed if inapprpriate behavir ccurs. Special mdificatins may be made t adapt t a child s needs. 1. The child is spken t privately in a firm but gentle manner regarding any unacceptable behavir. 2. If unacceptable said behavir cntinues, the child is remved frm the activity r area fr a cl dwn/timeut perid until bth the administrative staff member and the child feels the child is ready t return. 3. If the unacceptable behavir still cntinues, the child s parent will be called r spken with befre the child departs fr the day. 4. A Behavir Reprt will be cmpleted and placed in the camper's file any time a child receives a cl dwn/time ut. 5. If a camper receives three behavir reprts during his enrllment in camp, the camper's participatin in camp can be dismissed. 6. An Incident Reprt will be filed when there is evidence that a camper has engaged in behavir that results in prperty destructin, injury t an individual, inapprpriate tuching f an individual, multiple behavir reprts and ther inapprpriate behavir is grunds fr dismissal frm camp. 7. A child may be dismissed frm camp withut prir ntice t the parents if: a. A child engages in behavir that causes an individual t require medical attentin. b. A child displays vilent, uncntrllable behavir that puts thers in the prgram at risk. ** A child dismissed frm a sessin will nt be able t participate in any camp sessins fr the remainder f the year. ** Behavir incidents will never be dealt with in a demralizing, humiliating, r abusive manner. N child shall be subject t neglect, cruel, unusual, severe, r crpral punishment including: punishments which subject a child t verbal abuse, ridicule, humiliatin, denial f fd, use f bathrm facilities, punishment fr siling, wetting, r nt using the tilet. ** Verbal r physical abuse by a camper r by their parent is nt allwed. Abusive language includes statements that are cruel, humiliating, ridiculing, bullying and ful. Print Child(ren) s Name(s) Print Parent/Guardian s Name Signature Date ~ 11 ~

TIGER CAMPus REC Summer Day Camp Emergency & Medical Inf (One frm fr each camper) Camper Inf First Name: Last Name: Emergency Cntact Persn 1 First Name: Last Name: Address: City State Zip: What is the best way t cntact yu in case f an emergency Hme Phne, Daytime Phne, Other (rank 1-3?) Hme Phne: Daytime Phne: Other Phne: Relatinship t camper: Emergency Cntact Persn 2 First Name: Last Name: Address: City State Zip: What is the best way t cntact yu in case f an emergency Hme Phne, Daytime Phne, Other (rank 1-3?) Hme Phne: Daytime Phne: Other Phne: Relatinship t camper: Physician Name: Address: Phne Number: Health Insurance Cmpany Emplyee Grup # Plicy Hlder Name Member # ~ 12 ~

Camper's Name First Name: Last Name: Date f Birth: Age: Height: ft in Weight: lbs Medical Infrmatin Des yur child have any allergies? (Check all that apply) Nne Fd Medicatin Envirnmental Please list and explain: ther Anesthesia D these allergy/allergies require mnitring fr symptms, take actin if a reactin ccurs r give emergency medicatin? N Yes a Medical/Physical Care Plan and/r Request fr Administratin f Medicatin must be cmpleted. Please indicate any f the fllwing that apply t yur child: Any cnditin that may require special care, medicatin, r diet ADD r ADHD Asthma Seizures Heart truble Cntact lenses Diabetes Fainting spells Bleeding disrders Dentures Other Is yur child currently using any medicatin (prescriptin r ver-the-cunter), fd supplement r medical fd (such as electrlyte slutin)? N Yes, please explain If yes, des this need t be administered at the camp? N Yes a Medical/Physical Care Plan and/r Request fr Administratin f Medicatin must be cmpleted. ~ 13 ~

Date f last physical exam: Date f last tetanus sht: List any histry f hspitalizatin, utpatient surgery, r previus health cnditin that wuld be needed t assist the staff r medical persnnel in an emergency situatin: List any additinal useful infrmatin, such as fears, eating r sleeping habits r special rutines. This infrmatin shuld nt be medical r health related, as that infrmatin shuld be abve. Des yur child have any additinal restrictins? I have reviewed the prgram and activities f the camp and feel my child can participate withut restrictins. I have reviewed the prgram and activities f the camp and feel my child can participate with the fllwing restrictins r adaptatins. Please describe: Please attach a pht cpy f current immunizatin recrd. ~ 14 ~

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