2015 Day Camp Registration Forms
For Children in 1st through 6th grade
T-shirt size _________
Child’s Information (Please print legibly)
Child’s name (first/middle/last) __________________________________________________Name called ___________________________
Address ________________________________________________ City ______________________________ Zip____________________
____Male ____Female
Birth date ____/____/____
Age __________
T-Shirt Size_______________________
Check all that apply to your child:
____Allergies (type) ________________________________________________________________________________________________
____Dietary Restrictions_____________________________________________________________________________________________
____AD/HD
____Special circumstances (see Behavior Expectations and Discipline Policy and provide additional information if necessary)
Family Information
Mother/guardian’s name _____________________________________________________________________________________________
Home address ___________________________________________________ City _____________________ Zip _____________________
Phone Number ____________________________ Email___________________________________________________________________
Father/guardian’s name _____________________________________________________________________________________________
Home address ___________________________________________________ City ____________________ Zip _____________________
Phone Number____________________________ Email___________________________________________________________________
Emergency Information
Child’s doctor _____________________________________________________ Doctor’s phone __________________________________
Hospital preference ________________________________________________________________________________________________
Insurance company ___________________________________________________ Policy # _____________________________________
If mother, father, or guardian cannot be reached, call:
Name ___________________________________________________ Relationship to child ______________________________________
Phone Number____________________________________________
Name ___________________________________________________ Relationship to child ______________________________________
Phone Number____________________________________________
2015 Day Camp Programs Policy
Child’s Name_______________________________________
Please read each of the following policies and sign below to indicate your understanding of these policies.
Waivers/Permissions
I permit my child to participate in all the activities of day camp.
Field Trips – I permit my child to leave Highpoint Community Outreach on authorized trips under the
supervision of the Day Camp staff. I may review a written schedule of activities to be conducted off the
premises.
Photography - I permit usage of images of my child as a day camp program participant in internal and
external promotional material. This includes any printed material, broadcast and print advertising,
promotional videos and the website. I understand that my child’s name is not published.
Medical/Treatment Policies
Health – No camper may attend who is ill or a source of infection. If a camper becomes ill, the
parent/guardian will be contacted to pick up the camper. The parent/guardian will notify staff if their
camper contracts a communicable illness, and the camper may not return to camp until they are no longer
infectious.
Medication – Any medication will be administered only when directed in writing by the child’s parent or
guardian. However, in the event of an emergency in which the parent cannot be contacted, Day Camp
staff may take appropriate action in the best interest of the child.
Program Policies
Pickup Policy – I hereby acknowledge that the Day Camp staff will assume that either parent of the child
may pick up the child at any time during the program unless there is sufficient court documentation on file
that indicates otherwise. If someone else is to pick up my child, I will inform Day Camp staff ahead of
time and I understand that staff may ask them for their ID to verify.
Lost or Stolen Items – I understand that Highpoint Community Outreach and Highpoint Nazarene
Church and the Day Camp Staff are not responsible for any personal items lost or stolen at our programs.
Please do not bring any valuables (electronics, cell phones, toys, money, etc.) to camp. Please take a
moment when picking up your child to be sure they have everything that was brought to camp that day.
2010 Day Camp Programs Policy
I have read and understand all the policies stated above.
Parent/guardian signature ________________________________________ Date ________________
2015 Behavior Expectations and Discipline Policy
Child’s Name_______________________________________
It is important that staff maintain good order and discipline in all programs. Top objectives in all programs are
safety and a positive atmosphere for learning and developing social skills. We will make every effort to help
children understand clear definitions of acceptable and unacceptable behavior.
Highpoint Community Outreach will not permit:
1. Corporal punishment
2. Ridiculing, threatening, using an inappropriate loud voice
3. Leaving children unsupervised
4. Use of profanity
A child’s behavior is expected to be consistent with the following:
1. Use appropriate language at all times.
2. Listen, cooperate with staff, and follow directions.
3. Respect other children and staff, equipment and facilities, and yourself.
4. Maintain a positive attitude.
5. Stay in program areas – running away is not acceptable.
There is absolutely no tolerance of emotional, physical, verbal or sexual abuse, or of bullying, harassment or
teasing. There is no tolerance for fighting, physical violence, possession or use of weapons (including using
materials as weapons), or any actions or behaviors that threaten the safety of any individual. Smoking, the
consumption of alcohol and possession of illegal substances is not tolerated. No profanity.
The Discipline Policy
1. If a child is unable to comply with the behavior expectations, a conference will be held by the program director
with the child. The parent(s)/guardian will be notified.
2. If after the above meeting the child is still unable to comply with the behavior expectations, the program director
will set up a conference with the parent(s)/guardian.
3. If the child’s behavior continues to be disruptive and/or unsafe, the child will be subject to dismissal.
4. Failure of the parent(s)/guardian to attend conference(s) and cooperate will subject the child to dismissal.
Special Circumstances
Parents or guardians are required to inform the Day Camp staff, prior to the start of Day Camp, of any special
circumstances which may affect the child’s ability to participate fully and within the guidelines of acceptable
behavior, including but not limited to, any serious behavioral problems or special circumstances regarding
psychological, medical or physical conditions. Upon being informed of such circumstances, the Day Camp
Director may require a conference with the parent(s)/guardian to discuss issues created by these circumstances.
I have read, understand, and agree with the policies as stated in this document and have discussed the
expectations of behavior with my child.
____________________________________________________________________________________________
Parent/legal guardian signature
Date
Orders for Medication
To be completed by parent/guardian:
If it is absolutely necessary for the child named below to take medication during camp or child care hours, or in the event your
child has a medical condition of which we should be aware, please complete the information requested, sign and return this
form.
Child’s Name___________________________________________________________ Age ______________
Name(s) of Parent(s)/Guardian(s): ___________________________________________________________
Phone______________________________________________________
Medication:
Medication Prescribed____________________________________________________________________________________
Dosage______________________________________ Times(s) to Administer______________________________________
Possible Side Effects/Special Instructions____________________________________________________________________
_____________________________________________________________________________________________________
Medication Prescribed: ___________________________________________________________________________________
Dosage______________________________________ Times(s) to Administer______________________________________
Possible Side Effects/Special Instructions____________________________________________________________________
_____________________________________________________________________________________________________
Medical Condition(s): Please list below any allergies (do not include allergies to medications), asthmatic conditions or the
like which may require the Day Camp staff to administer the child’s medicine.
Condition Symptoms Medication/Dosage Special Instructions: ________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
______________________________________ ___________________________________________________
(Parent/Guardian Signature and Date) (Print Parent/Guardian Name)
Medicine Dosage Time(s) Given Caregiver’s Initials
_____________________ _____________________ _____________________ _____________________
_____________________ _____________________ _____________________ _____________________
_____________________ _____________________ _____________________ _____________________
Please Read: No medication (including Tylenol, other OTC medications, etc.) may be dispensed/applied without written
authorization from parent/guardian. Prescription drugs may only be dispensed from their original container.
Additional Information
Day Camp Dates:
Monday, July 6th – Friday, July 24th.
Day Camp Hours:
Structured Camp: 9:00 am to 3:00 pm
Drop-off time – NO EARLIER THAN 8:30 am. Doors will not be unlocked until 8:30 am
Pick-up time – 3:00 pm but NO LATER THAN 3:15 pm
Cost: $30 per child for the entire 3 weeks of camp.
Fees can be paid all at once up front, or
you may choose to pay $10 per week (fee due on Mondays).
attend the whole camp, but it is not a requirement.
We encourage your child to
The fee includes camp shirt, all activities,
We do not want the cost of camp to hinder anyone from
attending! Scholarships are available where hardships apply. Please contact Sharon Griner
pool, field trips, and meals.
([email protected] or 740-273-0368).
Donations:
So that everyone can attend camp regardless of income, we keep our fees very low
and rely heavily on fundraisers and donations. We appreciate donations of food, material items,
or cash to help us keep our camp affordable for all.
In addition, if you have membership passes
to our field trip locations (i.e. The Columbus Zoo, the pool), please let us know so your child can
use it.
Meals:
All donations are welcomed and appreciated!
Lunch and a snack will be provided each day. Please let us know if your child has any
dietary restrictions.
T-Shirts: All campers will be provided a t-shirt that will stay at camp to be used for field trips
and activities away from the facilities. They may take them home when camp is over.
What to wear and bring to camp:
•
Campers should wear comfortable clothes each day (shorts, T-shirts, tennis shoes).
•
Please apply sunscreen to your child before bringing them to camp. We will reapply as
needed during the day so please have your child bring sunscreen with them (make sure
your name is written on the bottle).
•
On swimming days send a bag with swim suit, towel, flip flops (can be in the bag and
worn to the pool only), and sunscreen. We do not have extras on hand.
•
Make sure names are written on everything.
•
Hats may also be worn outside if desired.
Items not permitted at camp:
•
Flip flops or open toe shoes/sandals.
•
Toys and stuffed animals.
•
Electronics of any kind, including phones, iPods, and hand held games.
•
Money.
If brought to camp, these items will be taken away and returned at the end of the day.
Questions, feedback, complaints
For immediate concerns contact the office of HCO at (740) 273-0368. You can also email Sharon
Griner at [email protected].