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Perpetual Motion Youth Camp
We have a fun, action-packed summer planned for 2015!
Our traditional Summer Camp 2015 , is designed for children 6 (entering 1st grade) to 12 years of
age. Our unique camp program “exclusively” includes “onsite” swimming & gymnastics activities 5
days a week. Other activities include a variety of games, and arts & crafts projects. Breakfast and
afternoon snacks are included in the fee. Parents are responsible for providing each child with a daily
lunch. Choose either 3 or 5 days weekly. Regular Camp hours are 8:00am—5:0pm with extended day
options. Sign up for just one week or up to 10 weeks!!!
General Information
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All campers must be pre-registered and pre-paid to
attend camp. Small weekly deposits are also required.
When registering please include tuition for the first
week of camp along with camp week deposits
You may sign up for any amount of weeks, and they
do not have to be consecutive. To guarantee space
the weeks must be predetermined. Billing is weekly.
If you sign up for the 3-day a week activities camp,
choose your days carefully. State regulated ratios
make it difficult to change days. Full payment is due
on the Friday before your child’s “scheduled” camp
week(s) regardless of attendance. Tuition due is for
the daily spots reserved. Late tuition fees apply each
week.
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Payment is accepted by check, Visa, MasterCard, or
Auto-Pay (discount given for auto-pay only).
Full time campers 2nd child receives a $10.00 per
week discount. Part time $6.00 per week discount.
Applications are accepted on a first come basis.
Camp space is limited. Register early!
A confirmation letter will be sent after we receive
your registration form and all weekly deposits.
Perpetual Motion reserves the right to terminate the
camp agreement should a camper’s behavior prove
detrimental to the health and safety of our campers,
staff or program goals.
Swimming lessons are available for an additional fee
(see attached forms).
Fees—General Registration $30/$20
5-day Camp
6-12 years
5 days
7:00am - 6:00pm
* $130.00 per week
 2nd child receives a $10.00 per week discount
$20 per week non-refundable deposits will hold your
child’s camp spots.
Fees include recreational swimming, gym, breakfast,
snack, and all craft activity materials.
Sign up for auto pay - receive a $4.00 per week discount!
3-day Camp
6-12 years
3 days
7:00am - 6:00pm
* $96.00 per week
 2nd child receives a $6.00 per week discount
$20 per week non-refundable deposits will hold your
child’s camp spots.
Fees include recreational swimming, gym, breakfast,
snack, and all craft activity materials.
Sign up for auto pay - receive a $2.00 per week discount!
Perpetual Motion • 1452 E. Brown School Road • Maryville, TN 37804
Call 865-984-1253 for more information. E-mail: [email protected]
www.perpetualmotion4kids.com
Summer Youth Camp 2015
General Daily Activity Schedule
Morning Camp Schedule:
7:00 - 8:00
Extended day campers early arrivals – Summer camp building
8:00 - 8:15
8:15 - 8:45
9:00 – 10:00
Regular day campers arrival time
Breakfast in their classroom
Gym activities in our 7,000 square foot gymnasium
Split time for each activity with each group going to the gym or the game room
10:00–11:00
Craft activities in camp building
Split time for each activity
Game room includes Foosball/Air Hockey, w-Box games etc
11:00-12:00
11:45-12:00
Outside play
Morning campers depart
Afternoon Camp Schedule:
12:00 –12:30 Lunch (in room)
12:30-1:30
Rest (quiet activities) & Change into swim suits
1:00—1:30
Swimming Lessons (for enrolled children)
1:30 – 3:00
Swimming in our on site pool
3:00 – 3:30
Change out of swim suits & afternoon snack
3:30 – 4:45
Game centers or Group games
4:45 – 5:00
Outside play or indoor games—Regular campers depart by 5pm
5:00 - 6:00
Extend day camper departures
This Daily Schedule may change due to weather, staffing and/or time to get to each activity area. Special
activities may also require more time to complete. Children will remain in the camp building during heavy rain
or visible or audio lighting.
SUMMER CAMP 2015 APPLICATION
Child’s Name:___________________________________________ (M)__ (F)__ Birth date: _____________________
Address:________________________________________________________________________________________
City:_________________________ State:__________ Zip: __________ Home Phone:(
) _____________________
School and grade your child will attend in August 2015-16
School:_____________________________________________________________ Grade: ______________________
Is this child in a special needs program?_______________
Mother’s Name:__________________________________ E-mail:___________________________________________
Home Phone: (
)___________________ Work: (
)__________________ Cell: (
) _________________________
Father’s Name:___________________________________E-mail___________________________________________
Home Phone: (
)___________________ Work: (
)__________________ Cell: (
) _________________________
Alternate Address:_________________________________________________________________________________
Person to contact in case of emergency other than parent if parent cannot be reached.
Name: _______________________________Address:__________________________Phone:(
)______________
Please list known allergies (food, environmental, medication), physical limitations, special needs:
________________________________________________________________________________________________
Please tell us how you heard about our program: Friend □ Website □ Daily Times □ Mint Magazine □ Internet □
Other □_______________________________________________________________________________
A NON-REFUNDABLE first weeks’ tuition must accompany this application. Also a $20 non-refundable deposit must
accompany each additional week enrolled. The undersigned understands that the fee will reserve a place at camp for
the child named on this application. All weeks may be changed with a three week in advance written notice. Reservation
and Payment obligations cannot be adjusted within 21 days of the start of any reserved week. We must prepare for
proper staffing and food. We hope everyone understands the importance of this requirement. I acknowledge that the
“total” weekly camp tuition is due for all reserved weeks regardless of attendance. I may be able to switch weeks if requested by the 21 day in advance rule and if space is available within the new requested week.
This tuition may not be applied to any other programs. This payment will be applied to the first registered camp week.
Make check payable to Perpetual Motion, or use Visa , Discover or Master Card. (Please circle card)
Card#_________________________________________________
Exp. Date:_________________________
Billing Address for the card: Street________________________ City____________________ Zip_________________
Signature:___________________________________________
(Required by applicant)
Please pay all weeks by credit card. Yes___ NO ___
Summer Camp 2015 reserved weeks & release
Summer Camp weeks must be predetermined. Weeks may be added if space is available.
I am registering my child for the following weeks: Tuition payment is required regardless of attendance. Reservations may
be changed to another week if space is available “and” if the reservation change request is within 21 days of the beginning
of each reserved week. We must pre plan and prepare for proper staffing, food and activity materials. We hope
everyone understands the importance of this requirement.
Please check the week #s and circle the days your child will be at camp. Minimum 3 days/week
1 □ May 25- May 29
T W Th F
M
2 □ Jun 1 - 5
T W Th
F
3 □ Jun 8 - 12
M T W Th F
Closed Mon. 5//25
6 □ Jun 29– 3
M T W Th
Closed Fri. 7/3
M
4 □ Jun 15 - 19
T W Th F
5 □ Jun 22 - 26
M T W Th F
Vacation Bible School Week
M
7 □ July 6 - 10
T W Th F
8 □ Jul 13 - 17
M T W Th F
9 □ Jul 20- 24
M T W Th F
10□ Jul 27- 31
M T W Th F
Tuition obligation is required regardless of attendance.
Child’s Name:_________________________________________
Parent signature:______________________________________
I have carefully selected the weeks and days.
2015 Summer Youth Camp - Release of Liability Waiver
FOR ANY STUDENT AND PARENT PARTICIPATING IN ALL CAMP ACTIVITIES INCLUDING GYMNASTICS OR SWIMMING ACTIVITIES:
Camp activities including swimming, gymnastics or any activity that involves motion, rotation, and height in a unique environment, carries with it a
reasonable assumption of risk. Perpetual Motion Youth Camp is bound by law to inform all participants and their parents or guardians of the risk
involved in these activities. Anyone participating in the Perpetual Motion Youth Camp activities including swimming and gymnastics (along with those
legally responsible for the participant) must sign the notice on the application and must adhere to the safety rules governing the swimming pools
and gymnasium. These rules are posted around the pool and gym areas.
In consideration for Perpetual Motion Camp’s acceptance of the applicant, and in consideration of the applicant’s opportunity to improve
swimming gymnastics and sport skills through the use of the staff, equipment and facilities, those legally responsible for the named enrolling student
realize the risk of injury involved and hereby agree to assume the responsibility of such for said student and further agree to save and hold harmless
the said school, its employees, and all others concerned, and to indemnify them against loss, intending to be legally bound, our signature is offered
below.
PHOTO RELEASE:
I hereby grant to Perpetual Motion Day Camp and/or its legal representatives and assigns, the irrevocable, absolute, and unrestricted right to use
and publish the likeness, portraits, photographs, film or videos of my child, or in which my child may be included, for advertising purposes. I hereby
release Perpetual Motion Day Camp and its legal representatives and assigns from all claims, royalties, and liability relating to the use of said likeness,
portraits, photographs or films/videos.
Parent Signature:_______________________________________________________________________Date:__________________________________
(Required by applicant– Please write—Pictures are not to be published if you desire not to sign)
Permission to Treat (optional)
I hereby give my permission to trained medical professionals to
administer emergency medical treatment to my child should an
accident or sickness occur in my absence.
Please list all adults (other than parents) with permission to
pick-up your child from class. We will not release a child to
anyone not authorized by you to pick-up. We may ask for
identification.
Child’s Doctor:__________________________________________
Name:____________________________________________________
Doctor’s Phone:_________________________________________
Phone #:( )_____________Address_____________________________
Signed:________________________________________________
Date:____________________________
Name:____________________________________________________
Phone #:( )_____________Address_____________________________
Perpetual Motion Swimming Lessons
984-1253
“Optional” Swimming Lessons for “Enrolled” Summer Camp and Preschool Students
Summer 2015
Dear Parents:
Summer Swim Lessons begin Monday, June 2nd thru July 25th. All Perpetual Motion families
can sign their child(ren) up for swim lessons. The lessons will be held two days a week for a
half hour each day, during the time they are attending camp. The cost for swim lessons is
$20.00 per week, and that would be billed with your tuition. Parents may begin the lessons
at any time during the summer. Lessons may continue into August for preschool children,
weather & staff permitting. Camp students will be billed only for the camp weeks attended.
Because of low student/teacher ratios for the preschool children, lessons are charged
regardless of attendance. Rain days or unexpected cancellations will be made up or refunded.
If you are interested in lessons, please fill out the form below and return it to the office. If
you have any questions please call Gary Thibodeau at 984-2075.
------------------------------------------------------------------------------------------—————-----Summer 2015 Swim Lessons
for enrolled students
Campers will be signed out from the camp
Staff and will, at that time, be the
Responsibility of the swimming instructor.
I would like my child(ren) __________________________________________________
to participate in swimming lessons. I understand that the fee for the lessons is $20.00 per
week, per child. The days and times will be arranged through the office. Rained out lessons
will be made up. I give my child permission to take swimming lessons at Perpetual Motion with
Gary Thibodeau and/or the on duty lifeguard/swim instructor. I understand (for enrolled
students only) that my child will be signed in and out of class by either Mr. Thibodeau and/or
the on duty lifeguard/swim instructor. My child will not be with a caregiver for 30 minutes of
the day twice a week.
Please sign my child up for lessons beginning ___/___/ 2015
___________________________________
Parent’s Signature
_______________
Date