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1 LSNC Summer Camp 2015 Camper Enrollment Form This form must be completed and signed by the parent or guardian of a student enrolling in the Summer Camp STUDENT INFORMATION/INFORMACION DEL ESTUDIANTE Student Nombre del Estudiante Grade/Grado School/Escuela Home Address_ Dirreccion del domicilio City/Zip Code Cuidad/Codigo postal Birth Date / / Sex: M F Race/Ethnicity (optional) Mo. Day Year Raza/Etnia (opcional) Home Phone( ) Telefono domiciliaro Parent/Guardian #1 Padre/Guardian #1 My Child Will Attend: Session 1 (Jul 6 - Jul 31) Mi hijo(a) va a atender Session 2 (Aug 3 - Aug 21) PARENT/GUARDIAN INFORMATION /INFORMACION DEL PADRE O GUARDIAN Nombre Relationship to student Live in same home? Yes No If no, please complete the following: Home Phone( ) Vive en el mismo hogar Si no viven juntos, completar lo seguiente Telefono domiciliario Home Address_ Zip Code Direccion del domicilio Apt # Codigo postal City: Bronx Brooklyn Manhattan Queens Staten Island Cuidad Correo electronico Work Phone ( ) Speaks English? Yes No Telefono del tarbajo Cell Phone ( ) If no, what language do you speak? Parent/Guardian #2 Padre/ Guardian #2 Nombre Relationship to student Live in same home? Yes No If no, please complete the following: Home Phone ( ) Vive en el mismo hogar Si no viven juntos, completar lo seguiente Telefono domiciliario Home Address_ Zip Code Direccion del domicilio Apt # Codigo postal City: Bronx Brooklyn Manhattan Queens Staten Island Cuidad Correo electronico Work Phone ( ) Speaks English? Yes No Telefono del tarbajo Cell Phone ( ) If no, what language do you speak? Child Sizes Camisa para nino S M L XL SELECT TEE-SHIRT SIZE Marque uno Adult Sizes Camisa por adultos S M L XL

2 Summer Camp 2015 Camper Enrollment Form FORMULARIO DE INSCRIPCION DE ESTUDIANTES This form must be completed and signed by the parent or guardian of a student enrolling in the Summer Camp El padre o tutor del estudiante que se inscribe en un Summer Camp, debe completer y firmar formulario 2 RELEASE OF CHILD-AUTORIZACION DEL NINO A. I give my child permission to walk home alone at dismissal. Yes No Autorizo a mi hijo regresar caminandosolo a casa a la hora de despedida B. My child will be picked up after camp by me or one of the following individuals: Tanto las personas que se indicant a continuacion como yo, buscaremos a mi hijo despues del horario escolar: 1. Authorized Pick-Up Person/Autoriza Persona de Relationship to student Home Phone ( ) Speaks English? Yes No Telefono domiciliario Cell Phone ( ) If no, what language do you speak? Following emergency medical care, my child may be released to the above named person Yes No En Caso de necesitar asitencia medica de emergencia, mi hijo puede ser entregado a la persona ques es menciona arriba 2. Authorized Pick-Up Person/Autoriza Persona de Relationship to student Home Phone ( ) Speaks English? Yes No Telefono domiciliario Cell Phone ( ) If no, what language do you speak? Following emergency medical care, my child may be released to the above named person Yes No En Caso de necesitar asitencia medica de emergencia, mi hijo puede ser entregado a la persona ques es menciona arriba C. DO NOT RELEASE MY CHILD TO THE FOLLOWING PEOPLE: NO ENTREGUEN MI HIJO A LAS SIGUIENTES PERSONAS Relationship to student PARENT/GUARDIAN SIGNATURE FIRMA DEL PADRE O GUARDIAN I give my child permission to participate in all after-school and summer program activities, including academic support, enrichment, social development, arts, sports, recreation, fitness, swimming, wellness and field trips. I understand that all program activities will be supervised by the program staff of the Lincoln Square Neighborhood Center. I agree that the professional staff of the after-school and summer program may meet with my child and review my child s attendance, achievement and guidance records when appropriate. Autorizo a mi hijo a participar en todas las actividades del programa postescolar o de verano, lo que incluye las actividades de apoyo académico, de enriquecimiento, de desarrollo social, artísticas, deportivas, recreativas, de aptitud física, nadando, bienestar y viajes de dia. Entiendo que todas las actividades del programa serán supervisadas por la organización comunitaria Lincoln Square Neighborhood Center. Consiento en que el personal profesional del programa postescolar se encuentre con mi hijo y controle la asistencia de mi hijo, los registros de logros y de dirección cuando sea apropiado. Parent/Guardian Signature Date

3 Summer Camp Student : Date of Birth / / Sex (M/F) HEALTH INSURANCE: Student s Doctor: Insurance Provider: of Insured: Phone: ( ) Policy Holder s ID#: MEDICATION: Please list all medications being taken and the dosage. Your child will be responsible for taking all necessary medication. ACTIVITY: Are there any activities your child cannot participate in? If yes, describe below. Yes No 1. Have or has ever had asthma? Yes No 17. Ever had asthma? Yes No 2. Use an inhaler for asthma? Yes No 18. Ever been diagnosed with a heart murmur? Yes No 3. Allergic to penicillin? Yes No 19. Ever had problems with knees or joints? Yes No 4. Ever been hospitalized? Yes No 20. Have problems with sleepwalking? Yes No 5. Ever had surgery? Yes No 21. Ever had chest pain during or after exercise? Yes No 6. Ever had frequent headaches? Yes No 22. Have any skin problems (itching, rash, etc.)? Yes No 7. Ever had a head injury? Yes No 23. Had mononucleosis in the past 12 months? Yes No 8. Ever been knocked unconscious? Yes No 24. Had problems with diarrhea/constipation? Yes No 9. Ever had frequent ear infections? Yes No 25. Wear contacts, glasses or protective eyewear? Yes No 10. Ever dizzy or passed out during exercise? Yes No 26. Has a recent injury/illness/infectious disease? Yes No 11. Have a history of bed-wetting? Yes No 27. Females: have an abnormal menstrual history? Yes No 12. Ever had an eating disorder? Yes No 28. Behavioral or emotional issues? Yes No 13. Ever had convulsions or seizures? Yes No Specify: 14. Ever had high blood pressure? Yes No 28. Individualized Education Plan? Yes No 15. Ever had back problems? Yes No 29. Have a physical disability? Yes No 16. Have diabetes? Yes No Specify: If you ve answered Yes to any question, please explain below and indicate the number of the question:

4 Summer Camp ALLERGIES & RESTRICTIONS: Medical Allergies (list all) Yes No Describe reaction and any management of reaction below Food Allergies/Restrictions (list all) Yes No Describe reaction and any management of reaction below Other Allergies (plants/insect /etc.) Yes No Describe reaction and any management of reaction below Dietary Does not eat meat Does not eat pork Does not eat eggs Does not eat chicken Does not eat dairy products Does not eat seafood Other (please describe): _ CHILD MEDICAL AND EMERGENCY CARE AUTHORIZATION & RELEASE This health history is correct and complete as far as I know. The person herein described has permission to engage in all activities except as noted in this application. I hereby give permission to the Lincoln Square Neighborhood Center to provide and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. I give permission to the Lincoln Square Neighborhood Center to arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I give permission to the physician selected by the Lincoln Square Neighborhood Center to secure and administer treatment, including hospitalization for the person named above. If my child requires emergency medical care and I cannot be reached, I give my consent to the above after-school program to obtain the necessary medical care for my child. I agree to pay all of the costs associated with the emergency medical care that my child receives. I understand that every effort will be made to contact me before and after medical care is provided. I understand that this consent will be in effect as of the date of my signing this form and will continue as long as my child is enrolled in this summer program. SIGNATURE: Parent/Guardian: PRINT NAME: Parent/Guardian: _ Date: / / Date: / /

5 Summer Camp Media Release Form I hereby consent to the participation of my child in interviews, the use of quotes, and the taking of photographs, movies or video tapes of my son/daughter in his/her after school or summer program related work by the Lincoln Square Neighborhood Center. I also grant the Lincoln Square Neighborhood Center the right to edit, use and reuse said products for non-profit purposes. Childs (print): Parent/Guardian : Parent/Guardian Signature: Date: Field Trip Permission Slip I understand that during the Lincoln Square Neighborhood Center summer program, my child may take part in field trips and excursions, either by public transportation or on foot. Also, I understand that trips and activities may include but are not limited to swimming, zoos, theme park rides. I further understand that my child will be chaperoned by Lincoln Square Neighborhood Center staff and will take all necessary precautions to protect my child from harm and injury. I acknowledge that when my son/daughter participates in any field trip, I assume full responsibility for all injuries or damages, which may occur or be sustained by my son/daughter. I hereby waive and release any and all rights and claims which may arise against the Lincoln Square Neighborhood Center or any of their employees, directors, group leaders, volunteers or agents, as a result of my daughter s participation in such filed trips, including but not limited to claims for personal injuries or property damage. Childs (print): Parent/Guardian : Parent/Guardian Signature: Date: Additional Information What goals do you have for your child s experience at Lincoln Square Neighborhood Center s Summer Camp? Has your child experienced any positive or negative life changes this past year? (Such as change of residence, illness, death in the family, separation/divorce, new siblings, etc.)

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