2016 Enrollment Application

Name of Camper(s): ______Camper: ______Camper: ______

Please initial that you have read the Enrollment Policies.

______Registration fee of $25 per child is taken in advance and is NON-REFUNDABLE. To secure a definite spot in our kid camp program, we must receive payment in full by your indicated payment enrollment date. If we do not receive payment in full by our requested date, your child will not have a spot in camp. I understand there will be no refunds for absences, change of days or camp withdrawals after JUNE 1st, 2016. Upon cancellation, a refund will be given within 60 days of submittal. Tuition is NON-REFUNDABLE after June 1st, 2016.

______I will be able to change my child’s daily or weekly schedule until June 1st, 2016. (No changes will be permitted after June 1st, 2016.) If your child is sick for 4 days or more, we will honor a credit to be used at our early arrival or extended day program. A credit also may be used to add days in 2016 or 2017 depending on availability. In the event of a medical emergency, a doctor’s note is required stating that your child will not be able to attend camp due to medical reasons. I understand that homesickness, minor illness, change of family plans, dismissal from the program and personal schedule conflicts/changes are not sufficient grounds for a refund or change of days that the child attends camp.

______I understand that my ENROLLMENT PACKET (Available on our website and at the club) contains documents and paperwork that I mustfill out prior to or at the time of registration. A completed Medical Form must be returned no later than JUNE 1st, 2016. If not received, my child will not be able to attend camp.

Please indicate the weeks/days you will be sending your child to camp. You may update this section until June 1st, 2016.

(If your children have different days/weeks, you MUST provide me with a separate list of days/weeks.)

June 20- June 24Monday Tuesday Wednesday Thursday Friday August 1- August 5 Monday Tuesday Wednesday Thursday Friday

June 27- July 1Monday Tuesday Wednesday Thursday Friday August 8-August 12 Monday Tuesday Wednesday Thursday Friday

July 5- July 8 Tuesday Wednesday Thursday Friday August 15- August 19 Monday Tuesday Wednesday Thursday Friday

July 11- July 15Monday Tuesday Wednesday Thursday Friday August 22- August 26 Monday Tuesday Wednesday Thursday Friday

July 18- July 22Monday Tuesday Wednesday Thursday Friday August 29- September 2 Monday Tuesday Wednesday Thursday Friday

July 25- July 29 Monday Tuesday Wednesday Thursday Friday

Please indicate the hours you will be sending your child to camp. You may update this section at anytime.

___ Drop Off Carline 8:50am to 9:10am____ Pick Up Carline 2:50pm to 3:10pm

(Early Arrival and Extended Day Program: $2 every 15 minutes/$8 an hour per child.)

You will pay for this program at the end of each camp week. We will bill your credit card on file if unpaid.

Drop Off___ 7:30am___ 7:45am___ 8:00am___ 8:15am___ 8:30am

Pick Up___ 3:45pm___ 4:00pm___ 4:15pm___ 4:30pm___ 4:45pm

___ 5:00pm___ 5:15pm___ 5:30pm___ 5:45pm___ 6:00pm

Payment Plan: January 1st to January 31stPacket

DEPOSIT: ______
_____$25 Registration Fee (Per Child) (NON-REFUNDABLE) ______

_____Payment in Full ______

_____50% Payment Today and 50% Auto Payment on February25th ______

_____50%Payment Today and 25% Auto Payment on February 25th and 25% on March25th______

_____25% Payment Today and 25% Auto Payment on February25th, March 25th and April 25th______

____ Other Payment option: ______

Payment Method: Cash Check Visa MasterCard DiscoverAMEX

Card # ______Card EXP ____/____/____

Auto Payment Signature ______

Emergency Contact Form

1st Camper Name: / 1st Camper Date of Birth:
2nd Camper Name: / 2nd Camper Date of Birth:
3rd Camper Name: / 3rd Camper Date of Birth:
4th Camper Name: / 4th Camper Date of Birth:
Address:
City: State: Zip:
Mother or Guardian First Name: Last Name:
Address: City: State: Zip:
Business Name: Phone Number:
Email Address:
Father or Guardian First Name: Last Name:
Address: City: State: Zip:
Business Name: Phone Number:
Email Address:

Emergency Contact (other than the parent or guardian)

First Name: / Last Name: / Relationship: / Phone Number:

Person (s) to whom the camper (s) can be released

First Name: / Last Name: / Relationship: / Phone Number:

Name of Camper (s) Physician/Medical Care Provider

Physician: / Practice: / Phone Number:
Insurance Coverage: / Policy #:

Allergies, Dietary, Special Needs, and Medication: Please provide a separate letter for each child’s needs.

Name of Camper: Allergies, Dietary, Special Needs, and Medication:
Name of Camper: Allergies, Dietary, Special Needs, and Medication:
Name of Camper: Allergies, Dietary, Special Needs, and Medication:

Parent/Guardian Signature: ______Date: ______

2016 Authorization Form

Please sign all spaces and fill in your child’s name for those activities and waivers you authorize.

(If more than one child, please write all names in each section)

Participation Waiver

I, ______, the parent/legal guardian of ______, who is my minor child, hereby give permission for my child to participate in all camp activities shown on sample and final schedules, special programs, and off-site trips, ETC. I understand that part of the camp experience involves activities, group arrangements and interactions that may be new to my child. These things come with certain risks and uncertainties beyond what my child may be used to. I am aware of these risks, and I am assuming them on behalf of my child. I realize that no environment is risk free and so I have instructed my child on the importance of abiding by the camp’s rules.

Medical Waiver

I, ______, the parent/legal guardian of ______, who is my minor child, hereby give permission to the representative of this camp to permit hospital personnel and/or a licensed physician to perform emergency treatment and/or administer drugs in conjunction with such emergency treatment. In case of a medical emergency, you understand that every effort will be made to contact you and your emergency contact. In event that you cannot be reached, you hereby give permission to this camp to secure proper treatment for your child.

I, ______, the parent/legal guardian of ______, who is my minor child, hereby give permission for Tylenol/Motrin/Benadryl to be given at the director’s discretion if unable to contact parents. You authorize minor first-aid procedures (band-aid/ointment/bee spray to be used by our Abington Club Staff.

Transportation and Planned Field Trips/Unscheduled Walking Trips

I, ______, the parent/legal guardian of ______, who is my minor child, hereby give permission for my child to be transported to and from off site locations and attend planned scheduled field trips with appropriate supervision by authorized camp personal. I agree that they will be transported to and from camp by a licensed and insured Pennsylvania bus company. I also give the above listed child permission to go on unscheduled walking trips to Alverthorpe Park located across the street with a police officer crossing at the light.

Photo Release

I, ______, the parent/legal guardian of ______, who is my minor child, hereby give permission for my child’s image, as a photo, video and/or audio recording, in camp marketing or website promotions.

Code of Conduct

I, ______, the parent/legal guardian of ______, who is my minor child, ensures my child will abide by the rules of the program and will explain to them that violation of rules related to (but not limited to) alcohol/drugs, inappropriate conversations/contact, or violence/bullying will result in dismissal from the program, with NO REFUND of camp fees.

Lost or Broken Items

I, ______, the parent/legal guardian of ______, who is my minor child, hereby agree to be aware that toys, games, electronics, and/or other items of value brought to camp are the sole responsibility of the camper and The Abington Club is not responsible for repair, replacement, ECT of any kind.

Personal Floatation Device- MUST BE PROVIDED BY PARENT

I, ______, the parent/legal guardian of ______, who is my minor child, hereby agree to provide my child with a personal floatation device if they cannot swim. My child must wear this device while entering The Abington Club’s indoor and outdoor pool areas. My child may not remove this device unless they are out of the pool area. This floatation device must remain at camp during the time my child attends. I understand my child will not participate in any swimming activities without this device.

(One will not be provided by The Abington Club.)