YES Camp Enrollment Application 2015
2015 Youth Enrichment Summer Camp Registration Form/Emergency Form/Health History 10 Martin Luther King Avenue, Morristown, NJ 07960 973-267-0136 x210 (office) – 973-898-1971 (fax) Incomplete forms will be returned. Please use a separate form for each camper! Camper’s Name_________________________________________________________________Age__________ Nickname_________________________ Date of Birth____/_____/____ Grade entering in Sept. 2015_________ Full Mailing Address ___________________________________________________________________________ Ethnicity (Optional) ____ African American _____Asian/Pacific Islander ____Caucasian ____ Hispanic ____ Other T-shirt Size: ___Child small (S) ___Child medium (M)___Child large (L) ___Adult S ___Adult M ___Adult L Mother’s Name_____________________________________ Email_____________________________________ Home Phone_____________________ Cell Phone_______________________ Work Phone_________________ Employer________________________ Occupation______________________ Work Hours_________________ Father’s Name______________________________________ Email_____________________________________ Home Phone_____________________ Cell Phone_______________________ Work Phone_________________ Employer________________________ Occupation______________________ Work Hours_________________ Camper’s Living Arrangements During Camp: ( ) Both Parents ( ) Mother ( ) Father ( ) Other _____________ REQUIRED: A copy of my child’s most current immunization record is attached. Initial_____ Those authorized to pick-up camper if parent/guardian cannot be reached immediately (must be 18 or older): Name___________________________ Relationship_________________ Phone No._______________________ Name___________________________ Relationship_________________ Phone No._______________________ Who may not pick up the child? __________________________________________________________________ Child’s Doctor or Clinic__________________________________________ Phone No.______________________ Address_____________________________________ Medical Insurance ID______________________________ Preferred Medical Facility for Emergency Treatment__________________________________________________ Allergies: _________________________________________ Medication prescribed: _______________________ Epipen Required? Yes___ No___ Medication to be taken daily while at camp:______________________________ Note: All medication (prescription & over-the-counter) must be given to the Health Coordinator on the first day of camp with a completed Medication Authorization Form. (Inquire at the sign-in desk for form.) Medical/Orthopedic/Emotional/Learning Conditions?__________________________________________________ If so, please explain_______________________________________________ Date of Last Physical:___/___/___ This health history is complete and accurate to the best of my knowledge. Initial_____ I hereby enroll my child in Youth Enrichment Summer Camp. In signing this application, I certify that he/she is healthy and free of problems that could adversely affect him/her or other youth. Initial_____ (OVER) Camper’s Full Name___________________________________________________________________________ I understand that my child must comply with the camp’s rules and standards of conduct and that the organization may terminate my child’s participation in the camp if s/he does not maintain these standards. Neither the Community Development Corporation of Northern New Jersey (CDC|NNJ) nor Calvary Baptist Church in Morristown, New Jersey (CBC) are responsible for lost, stolen or damaged personal articles. CDC|NNJ and CBC do not assume the risk for youth that travel to or from the camp site without supervision or authorization. CDC|NNJ and CBC assume no responsibility for youth once they leave the premises. I understand and acknowledge that participation in the activities involves inherent risks of injury to my child including risks associated with transportation by walking, bus, amusement park rides, and water rides. Initial_____ I hereby grant CDC|NNJ and its agents full authority to take whatever actions they deem necessary regarding my child’s health and safety, and I fully release them from any liability. I understand that prudent attempts will be made to contact the undersigned immediately, in the event of an emergency. I understand that I will be responsible for payment of all medical and medication bills. Initial_____ ___ Apply the multi-camper discount, I am enrolling ______ campers. Names: 1._________________________ 2._________________________ 3. _________________________ ___ I have applied for CFR, TANF or other childcare assistance (if other explain below) ___________________________________________________________________________________________ ___ I have attached a financial aid application complete with requested information. th Rising K – 10 Graders st __6 weeks, 2 sessions ($900) $225 due May 1 _____ th th $225 due May 22 nd th June 29 – Aug. 7 _____ th $225 due June 12 _____ $225 due June 29 Add $25 late fee to each delinquent payment, _____ _____ __3 weeks (choose 1 session) * ($525) th __ June 29 – July 17 th th __ July 20 – Aug. 7 th st nd _____ th $131.25 due June 12 _____ $131.25 due June 29 _____ Add $25 late fee to each delinquent payment _____ $131.25 due May 1 _____ $131.25 due May 22 th th *Upgrade from 1 to 2 sessions on/after July 20 – add $525 due upon change _____ __ Club OT AM (Before Care 7:30-9am) FREE __ Club OT PM (After Care 4-6pm) __ $100/six-weeks _____ __ $75/three-week session st _ _ One-time, non-refundable registration fee if registered on or before May 1 st _ _ One-time, non-refundable registration fee if registered after May 1 th Registered before April 15 _____ $50 $75 Apply $75 early registration discount (_____) TOTAL DUE ______ Make checks payable to: Community Development Corporation of Northern New Jersey I understand the tuition fees schedule. Initial_____ I authorize CDC|NNJ and CBC to have and use photographs, slides, videotapes and comments of the person named on this application as needed in promotional materials. I understand that CDC|NNJ and CBC are not-forprofit organizations offering programs that may not otherwise be available. Initial _____ I agree to indemnify CDC|NNJ and CBC and their employees and agents for any loss, damages, claims, liabilities, costs or expenses arising out of my child’s participation in activities. Initial_____ The above information is accurate. I understand that it is my responsibility to notify the camp immediately, in writing, of any changes. Initial_____ Signature of Parent or Legal Guardian: ______________________________________ Date_______________ Completed applications may be emailed to [email protected]
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