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2015 Summer Camp Registration Form
For Early Childhood
20 Nelson Road Ithaca NY 14850 • 607-256-2020 • ithacawaldorf.org • [email protected]
Before June 1, a $100 non-refundable deposit per week, per child holds your space.
Full payment of $230 per week, per child is due June 1. Please mail the completed
application and deposit or full payment to The Ithaca Waldorf School, 20 Nelson
Road, Ithaca, NY 14850. Please fill out one per child.
-Please Print-
Child’s Full Name: _____________________________
Birth Date _____________
Family Information:
____________________________________
1st Family Member’s Full Name
___________________________________
2nd Family Member’s Full Name
____________________________________
Home Address
___________________________________
Home Address (if different)
____________________________________
Cell #
Work #
___________________________________
Cell #
Work #
____________________________________
Email address
___________________________________
Email address
Emergency Contact Information in case parents are not available:
Name and relationship to child: _____________________________________________
Cell#
Work #
Health notes (medical conditions, allergies, other concerns):
______________________________________________________________
_________________________________________________________________
Please choose the week(s) you would like the child to attend:
June 22 through June 26:
June 29 through July 3:
July 6 through July 10:
Authorization for pick up (other than parents):
Name and relationship to child: ______________________________________________
Cell#
Work #
AUTHORIZATION TO TREAT MINOR
In an emergency, I authorize any medical treatment in my absence. I agree to hold harmless the
Ithaca Waldorf School, its employees and agents, and the physician or hospital treating my child,
exclusive of negligence, from any injury or sickness occurring during camp. I understand that if my
child requires an inhaler, Epipen, or any other medication that I am responsible for providing it to the
instructor.
Signature of Parent/ Guardian: _____________________________
Date:____________
PHOTO AND ARTWORK RELEASE
I give permission for my child(ren) to be photographed and to have her/his image and and/or
artwork on publications and/or the website.
Signature of Parent or Guardian: _____________________________
Date:____________
About the Camp:
Built upon the Waldorf understanding of the child, we provide children ages 3 to 6 with a nurturing
environment which allows the imagination to unfold in a beautiful and lush summertime setting. Our camp is
led by Rena Guinn and Katie Bond, both Early Childhood teachers during the school year, who are
enthusiastic about all the fun that summer may bring and aware of the unique opportunities the season
presents to children, families, and teachers.
The forest and field setting is the ideal place for children to experience an Upstate New York summer to the
fullest. The majority of our day will be spent outside in our magical forest and field, equipped with
comfortable shady spots, a sand play area, ample water sources, climbing tree, jump ropes, and lots of
room to run around. We strive to provide a world where children can experience the wonder of childhood.
Activities include crafting, outdoor games, and story time. Within the rhythm of our day, time for snack,
lunch, and nap are included. A healthy morning snack is provided by the camp. Children bring their lunches
from home.
What should my child bring each day?
This is of course up to the parent, but we ask that children come with items similar to those that they would
use during the school year.
-rain boots
-outdoor shoes appropriate for running
-change of clothes
-hat & sunglasses (if desired)
-wind breaker
-sweater
-sunscreen (if desired)
-towel (for water play)
-bathing suit (if desired)
About the Instructors:
Rena Guinn first became involved with the Ithaca Waldorf School in 2012. She started as an After
School Teacher and Early Childhood Assistant. She is very passionate about being involved and supporting the
Ithaca Waldorf community. Rena was home schooled most of her life through Waldorf-inspired learning. She is
always studying something new and bringing what she learns to others. She has taught painting classes at the
Community School of Music and Art. She is also passionate about organic farming and outdoor survival skills
and likes to bring this to her teaching. Some of her hobbies include natural building, carpentry, music, and
gardening.