Summer 2013 Application Checklist

Transcription

1 Summer 2013 Application Checklist \ Forms Camp Application Payment Form Authorization for Medication /Treatment Reminder Complete registration form Checks should be made payable to Camp Nova. We also accept Cash, Visa, Master Card, and American Express. No Refunds. Must be signed by both parents and physician. For all campers. Non University School Students: Extra Medical Forms Non University School Students must submit the following two forms: DH/HRS 3040 form and a DH/HRS 680 form which can be requested from your child s physician. Visit : Parent FAQs Orientation Date: June 8 th, 2013 Time: 10am-12pm Location: Epstein Center

2 Camper 1: Name: M F D.O.B: Grade Entering in the fall: School: Camper 2: Name: M F D.O.B: Grade Entering in the fall: School: PARENT/GUARDIAN CONTACT INFORMATION Mother/Guardian/Co-Parent Father/Guardian/Co-Parent Name: Name: Address: Address: City: State: Zip Code: City: State: Zip Code: Home #: Work #: Home #: Work #: Cell #: Cell #: Address: Address: AUTHORIZATION TO RELEASE: Other than parent(s), please list additional people who are authorized to pick up the camper. EMERGENCY CONTACTS RELEASE OF LIABILITY: As a parent or legal guardian of the above camper(s), I/we agree for the noted camper(s) to attend Camp Nova: Summer Camp and all off-campus activities. I/we give permission for camper(s) to engage in all prescribed activities as noted. I/we authorize and give consent to any licensed health professional to perform upon or administer to camper(s) any reasonable, necessary medical treatment. Initial: I/we authorize the use of my camper(s) photograph(s) in camp publications, web sites, and or/or advertisements. I/we hereby release Nova Southeastern University, Inc., its trustees, officers, agents, and employees, the University School, its officers, employees, agents and instructors from any and all liability for any injury, damage, claim, demand, action, loss, liability, cost and expense (including, without limitation, reasonable attorney s fees) of any nature that I/we may at any time have or incur, while taking part in a University School/ program. NON-REFUND POLICY: A NON REFUNDABLE DEPOSIT OF $100 PER CHILD/PER SESSION IS REQUIRED FOR YOUR CAMPER TO BE REGISTERED. THIS WILL BE DEDUCTED FROM THE TUITION FOR EACH SESSION. Initial: I understand the deposit enclosed will be applied toward one session of each camper s basic fee. I agree to pay the balance on or before April 5, I am aware this deposit is non-refundable and will be forfeited if my child does not attend. There is no-refund for late arrival or early departure for a camper dismissed for disciplinary action or for emergency weather situations. If payment procedures are not followed, the person responsible for payment will be sent to collections. Refunds are not issued if a child is dismissed due to disciplinary action based on his/her behavior or misconduct. Only in the case of an extreme medical emergency will this policy be reviewed by University School. Refunds will also not be issued in the event that the National Hurricane Center broadcasts a hurricane/tropical storm warning for our area. In such a case, will cancel its program for the duration of the inclement weather. We reserve the right to cancel programs if there is insufficient enrollment. Parent/Guardian Signature: Date:

3 (One form per camper) Camper 1: Name Date of Birth Age Female Male Grade in fall Shirt Size Child S M L Adult S M L Jr. (K-1 st Grade Only) Teen Travel Camp (8 th -10 th Grade Only) C.I.T. (9 th -12th Grade Only) Cheer Camp (2 nd -8 th Grade Only) Session 1: 6/10/13-6/21/13 Session 1: 6/10/13-6/21/13 Session 1: 6/10/13-6/21/13 Session 1: 6/10/13-6/21/13 Session 2: 6/24/13-7/5/13 Session 2: 6/24/13-7/5/13 Session 2: 6/24/13-7/5/13 Session 2: 6/24/13-7/5/13 Session 3: 7/8/13-7/19/13 Session 3: 7/8/13-7/19/13 Session 3: 7/8/13-7/19/13 Session 3: 7/8/13-7/19/13 Session 4: 7/22/13-8/2/13 Session 4: 7/22/13-8/2/13 Session 4: 7/22/13-8/2/13 Session 4: 7/22/13-8/2/13 Volleyball Camp Basketball Camp Jr. Lifeguard (2 nd -8 th Grade Only) (2 nd -6 th Grade Only) (4 th -8th Grade Only) Week 7:7/22/13-7/26/13 Week 1: 6/10/13-6/14/13 Session 2: 6/24/13-7/5/13 Week 2: 6/17/13-6/21/13 CORE CAMPS (Grades 2-8 Only) Full Day Camps Campers will spend each full day participating in the activity as well as participate in swimming, fieldtrips and camp-wide activities. SESSION 1: 6/10/13-6/21/13 SESSION 2: 6/24/13-7/5/13 SESSION 3: 7/8/13-7/19/13 SESSION 4: 7/22/13-8/2/13 AM PM BEFORE CARE (7:30-8:30 AM) AND/OR AFTERCARE (3:30-5:30 PM) AM PM AM PM AM PM RELEASE: THIS STATEMENT MUST BE SIGNED FOR ATTENDANCE. The person herein described has permission to engage in all prescribed activities as noted. Initial: MEDICAL INFORMATION Your camper s health and safety is very important to all of us at. Please be assured that we will share any and all medical/allergy information with your campers counselors, including all camp vendors (i.e. Magic Program) who interact with your children. Please let us know if there are any additional concerns that the staff should be aware of?

4 (One form per camper) Camper 2: Name Date of Birth Age Female Male Grade in fall Shirt Size Child S M L Adult S M L Jr. (K-1 st Grade Only) Teen Travel Camp (8 th -10 th Grade Only) C.I.T. (9th-12 th Grade Only) Cheer Camp (2 nd -8 th Grade Only) Session 1: 6/10/13-6/21/13 Session 1: 6/10/13-6/21/13 Session 1: 6/10/13-6/21/13 Session 1: 6/10/13-6/21/13 Session 2: 6/24/13-7/5/13 Session 2: 6/24/13-7/5/13 Session 2: 6/24/13-7/5/13 Session 2: 6/24/13-7/5/13 Session 3: 7/8/13-7/19/13 Session 3: 7/8/13-7/19/13 Session 3: 7/8/13-7/19/13 Session 3: 7/8/13-7/19/13 Session 4: 7/22/13-8/2/13 Session 4: 7/22/13-8/2/13 Session 4: 7/22/13-8/2/13 Session 4: 7/22/13-8/2/13 Volleyball Camp Basketball Camp Jr. Lifeguard (2 nd -8 th Grade Only) (2 nd -6 th Grade Only) (4 th -8 th Grade Only) Week 7:7/22/13-7/26/13 Session 1: 6/10/13-6/14/13 Session 2: 6/24/13-7/5/13 Session 2: 6/17/13-6/21/13 CORE CAMPS (Grades 2-8 Only) Full Day Camps Campers will spend each full day participating in the activity as well as participate in swimming, fieldtrips and camp-wide activities. SESSION 1: 6/10/13-6/21/13 SESSION 2: 6/24/13-7/5/13 SESSION 3: 7/8/13-7/19/13 SESSION 4: 7/22/13-8/2/13 BEFORE CARE (7:30-8:30 AM) AND/OR AFTERCARE (3:30-5:30 PM) AM PM AM PM AM PM AM PM RELEASE: THIS STATEMENT MUST BE SIGNED FOR ATTENDANCE. The person herein described has permission to engage in all prescribed activities as noted. Initial: MEDICAL INFORMATION Your camper s health and safety is very important to all of us at. Please be assured that we will share any and all medical/allergy information with your campers counselors, including all camp vendors (i.e. Magic Program) who interact with your children. Please let us know if there are any additional concerns that the staff should be aware of?

5 Payment Form DEPOSITS AND PAYMENT A non-refundable deposit of $ per camper, per session must accompany the application for registration to be complete. This deposit will be applied to the camp fees. The person responsible for payment must sign the application form. has a no-refund policy. All accounts must be paid in full by May 3 th, 2013 Upon receipt of the application, a confirmation will be sent that includes the balance due and the dates by which payment must be received. If you do not receive a confirmation within two weeks of sending in the application, please call the camp office at (954) Camper 1 Name: Camper 2 Name: Camper 1: 2 Weeks 4 Weeks 6 Weeks 8 Weeks $ $1, $1, $2, Camper 2: 2 Weeks 4 Weeks 6 Weeks 8 Weeks $ $1, $1, $2, Teen Travel 2 Weeks 4 Weeks 6 Weeks 8 Weeks Teen Travel 2 Weeks 4 Weeks 6 Weeks 8 Weeks $ $1, $1, $2, BASKETBALL CAMP Week 1 Week 2 $ $ Before Care $31.25 $31.25 $32.50 $32.50 After Care $62.50 $62.50 CIT Weeks 1-4 Weeks 5-8 $ $ $ $1, $1, $2, BASKETBALL CAMP Week 1 Week 2 $ $ Before Care $31.25 $31.25 $32.50 $32.50 $62.50 $62.50 CIT Weeks 1-4 Weeks 5-8 $ $400.00

6 Jr. Lifeguard 2 Weeks $ Before Care $62.50 $65.00 After Care Cheer Camp: $ Weeks 4 Weeks 6 Weeks 8 Weeks $ $ $1, $1, Jr. Lifeguard Cheer Camp: 2 Weeks 4 Weeks 6 Weeks 8 Weeks $ $ $1, $1, Weeks $ Before Care $62.50 $65.00 After Care $ Additional T-shirt order: $15.00 each: Tote bag: $18.00 each: Total: $ Additional T-shirt order: $15.00 each: Tote bag: $18.00 each: Total: $ Pay By: Check Cash MasterCard Visa American Express -ALL DEPOSITS ARE NON-REFUNDABLE- Make check payable to: Credit card type: VISA MASTERCARD AMEX Cardholder s name: Signature: Credit card #: Billing Address: Billing Zip Code: Expiration Date: / / Amount: $ Registration forms can be faxed or submitted to the Camp Office located in the University Lower School

7 Authorization for Medication/Treatment 2013 This form MUST BE SIGNED BY THE CAMPER S PARENT/GUARDIAN AND PHYSICIAN. No student will be permitted to participate in University School s Summer Programs without returning this form with BOTH signatures. The purpose of this form is to allow University School s nurse and directed staff to carry out minor medical treatment (such as band-aids) when needed. Even if you do not want the program to administer any type of aid to your camper this form must be turned in. If physician s signature is not present we CANNOT give out any authorized medication to camper if needed! Any medication sent from home, including OTC and prescription, must be in the original container. Only medications/treatments authorized by a physician may be administered by Summer Program personnel. It is your responsibility to notify Summer Program personnel when there is a change in medication/treatment regimen. Student Name: Allergies: Date of Birth: Age: Grade: OTC (Over-the-counter) STANDING ORDERS MEDIATION DOSAGE FREQUENCY INDICATION FOR USE Acetaminophen Ibuprofen Benadryl Tums Caladryl Lotion Neosporin Chloraseptic Spray OTHER MEDICATIONS MEDICATION DOSAGE FREQUENCY INDICATION FOR USE TREATMENTS DURING CAMP HOURS (i.e.; nebulizer, blood glucose checks, etc): ADDITIONAL FORMS NEEDED! IMPORTANT: Broward County Dept. of Health requires us to have a physician signed copy of current (within one year of the first day of Summer Programs) Certificate of Good health, known as the DH/HRS 3040 (YELLOW) AND DH/HRS 680 (BLUE) FORMS. ALL NON UNIVERSITY SCHOOL STUDENTS MUST SUBMIT ORIGINAL COPIES OF THE BLUE AND YELLOW FORMS IN ADDITION TO THIS AUTHORIZATION FOR MEDICATION/TREATMENT FORM. A sample of the blue and yellow sheets can be found in this packet. / / Physician s Name (Please print) Physician s Signature and Stamp Date Physician s Phone: ( ) Physician s Fax: ( ) I grant the nurse, and/or primary designee the permission to assist or perform the administration of each medication or treatment/procedure to/for my child during Summer Programs including when he/she is away from the property on scheduled field trips. / / ( ) Parent/Guardian Name (Please print) Signature of Parent/Guardian Date Cell Phone Number Home Phone: ( ) Work Phone: ( )