South Shore Day Camp 2015 Registration Information and Fees Parent Information Name: Address: Town: Zip: Home Phone: Work Phone: Cell Phone: Parent s Email address: Parent s Email address: Please circle each session that your child (ren) will attend camp. Availability of sessions is on a first come first serve basis. We will not refund for sessions chosen but not used, except for a Medical reason supported by a physician s note. $360.00 per session. (10% discount for siblings) Please add $90.00 per session per child for Transportation Please add $60.00 per session per child for extended hours per child (if needed) A two week non-refundable deposit is due with this agreement (to be applied to the last session s camp fee). Session #1 July 6 th July 17 th Session #2 July 20 th July 31 st Session #3 Aug 3 rd Aug 14 th Session #4 Aug 17 th Aug 28 th Child Information Name 1: D.O.B.: / / Current Grade: School (September 15): Name 2: D.O.B.: / / Current Grade: School (September 15): Name 3: D.O.B.: / / Current Grade: School (September 15): In order to be successful at camp, will your child need any special accommodations? [ ] yes [ ] no If yes, please check all the reasons that we should know about which apply: behavior social/emotional developmental delays other. physical abilities health issues If you checked yes, a staff person will call you to discuss if the accommodations your child needs will be possible and to develop a plan so that your child will have a good camp experience. Please tell us the best number and time of day to reach you. Phone #: Best time of day: Payment for sessions 1 & 2 is due by June 19 th. Payment for sessions 3 & 4 is due by July 17 th. I will need extended care at the following site: (please circle choice) Quincy Atlantic Randolph St. Mary s Weymouth Make Payable to: South Shore Stars Amount enclosed: Check# 200 Middle Street E. Weymouth MA 02189 MC/Visa # Expiration Date: Parents Signature : Date :
South Shore Day Camp Open House Saturday, April 25th at Hale Reservation 11AM 1:30PM (rain date April 26th) What does it cost? * The actual cost of South Shore Day Camp is over $550.00 per session. Because Stars is committed to keeping our camp affordable to all South Shore working families, we use other funding sources so that we can charge you $450.00 per session for this wonderful camping experience. A 10% discount is available for siblings. * $450.00 includes $90.00 for transportation. If you choose to transport your child to and from camp, you will pay $360.00/two week session or $390.00 if you transport one way. * Extended care is available until 6:15pm in Randolph and 6:00pm in Weymouth and Quincy, at an additional cost of $60.00 per session. Directions to Hale Reservation (from the South Shore) Take Route 128 North to Exit 16B (Rte. 109 West) Follow 109 West approximately one mile and turn Right onto Dover Rd. (street sign also says Highway Garage) Follow Dover Rd. approximately ½ mile and turn right onto Carby St. Follow Carby St. right into Hale Reservation and SSDC parking is available in the first big lot on the left. (Cat Rock Parking Lot) Bus stops are conveniently located at the sites listed below: Quincy Randolph Weymouth Bernazzani School, Lincoln Hancock School, Parker School, Quincy High School Young School, Randolph High School, St. Mary s School, Donovan School Abigail Adams School, Pingree School, Joseph Fern Court/Lake Street, Seach School, Weymouth High School, Nash School A convenient registration form is available on the other side of this sheet!
South Shore Stars At Hale Reservation 2015 Health History, Emergency Contact, and Release Form 80 Carby Street, Westwood, MA 02090 Tel (781) 326-1770 Fax (781) 326-0676 www.halereservation.org 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 Email Cell Phone Email 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
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
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:
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.
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
South Shore Day Camp - 2015 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) 328-1572 135 Rawson Rd. (617) 328-1572 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) 331-3685 4:55 200 Middle Street (781) 331-3685 5:05 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 781-963-1588 4:40 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.
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: