Cassandra Wyzik – Camp Director

1301 S. Patrick Dr. Satellite Beach, Fl 32937

www.FitWithCassandra.com

(504) 717-5378

Fit & Fun Day Camp - Summer 2013

Circle weeks your child will be attending. Weeks are Monday-Thursday from 9am to 1pm for 5-11 year olds:

June 10th–13th June 17th–20th June 24th–27th July 8th–11th July 15th–18th July 22nd–25th

Weekly Fee: $110/week for 1 child, $100/week for additional siblings

·  Price includes all equipment children will be using, facility fees, and prizes.

·  Fees are due at the time of registration for each week to ensure a secured spot.

PLEASE PRINT CHILD’S INFORMATION

______Birthdate ____/____/____

Last Name First Name Nickname

Address ______

May we take pictures of your child to use on flyers, our website, or brochures? YES NO

PARENT INFORMATION
(Circle preferred contact) / FATHER’S INFORMATION / MOTHER’S INFORMATION
Name
Cell # / ( ) / ( )
Work # / ( ) / ( )
Place of Employment
E-mail address

·  I understand that I am responsible for sending my child in appropriate athletic shoes (no crocs, no sandals, no heels, no platforms) and athletic clothing.

·  I understand that I will need to send a healthy lunch and refillable water bottle for my child.

·  I understand that my child should wear sunscreen or other sun protection as playing outdoors will be a daily part of the curriculum (whenever weather permits).

·  I understand that all my children’s belongings should have their name on it to avoid confusion.

·  I understand that my child is expected to be toilet independent and not require assistance.

·  I understand that drop off time is between 9:00-9:15am and pick up time is between 12:45-1:00pm. Late pick-ups will result in a fee of $5 per 5 minutes past deadline.

·  I understand that there are no refunds or make up days once my child is registered.

·  I understand that space is limited and in the unlikely event that a minimum enrollment isn’t met, camp may be cancelled.

Print ______Signature______Date______

Camper’s Name:______Relationship to Camper______

Child’s Medical Information

Allergies &

Medical Conditions / Food Allergies / Medication Allergies / Allergic to Bug Bites? / Medical Conditions
Any Daily Medications? /
Asthma?

Emergency Contacts and People Authorized to Pick Up My Child

Please list persons other than mother or father to be contacted in case of accident if parent cannot be reached and are authorized to pick up your child. They should be able to pick up with 30 minutes.

Please Print Information

EMERGENCY CONTACTS / Contact #1 / Contact #2 / Contact #3
Name
Home Phone / ( ) / ( ) / ( )
Cell # / ( ) / ( ) / ( )
Work # / ( ) / ( ) / ( )
Relationship

CUSTODY: (circle one) BOTH PARENTS FATHER ONLY MOTHER ONLY

If a parent is NOT allowed to pick up the child, please provide paperwork to that effect so I can enforce it.

Authorization for Emergency and Minor Medical Care

If my child, ______, should become ill or injured at Fit & Fun Day Camp, I

understand Cassandra Wyzik (who is CPR/AED/First Aid certified and a certified fitness professional) will:

1)  Call 911 if needed

2)  Contact me immediately

3)  Contact the person(s) I have designated if I cannot be reached.

4)  In cases of minor injuries: administer ice, band-aids, and other appropriate measures.

·  Should Cassandra Wyzik be unable to reach me and/or the person(s) designated, they are authorized to make a judgment call in my child’s best interest and do whatever she feels necessary to ensure my child’s care.

·  The physician and/or medical facility are authorized to administer emergency medical treatment necessary to ensure the health and safety of my child.

·  I will accept responsibility for payment of medical services rendered.

Print ______Signature______Date______

Camper’s Name:______Relationship to Camper______

Fit & Fun Day Camp - Guidelines in Case of Illness

I understand I need to keep my child home if he/she has had any of the following within the past 24 hours:

1)  FEVER equal to 100 degrees or greater

2)  A constant untreated COUGH.

3)  Signs of a possible communicable disease. i.e. skin rash, inflamed eyes

4)  DIARRHEA and/or VOMITING

5)  Green or yellow tinged nasal discharge

We are not equipped to take care of sick children and cannot accept any responsibility to do so. Even though we would like to help you out, this is often impractical and sometimes impossible. We reserve the right to use our own judgment as to thewellness of a child and to decline to accept or admit a child to camp, even though we have received a doctor's release forthe child to enter or re-enter camp. You agree we may keep your child out of camp upon our determination that your child is sick and that you willcome to camp and take your child home upon being notified to do so.

Fit & Fun Day Camp policy is that kids sent home during the camp day due to sickness or showing signs of illnessshould stay home one more day even with a doctor's release for the child to re-enter camp.

Print ______Signature______Date______

Camper’s Name:______Relationship to Camper______

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Fit & Fun Day Camp – Liability Waiver

I, the undersigned, being aware of my child’s health and physical condition, and having knowledge that my child’s participation in the Fit & Fun Day Camp has inherent risks, as with any physical activity.

Having such knowledge, I hereby release Fit With Cassandra, their representatives, agents, and successors from liability for accidental injury or illness which my child may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent for my child to participate in said program.

I agree to disclose any physical limitations, disabilities, ailments, or impairments which may affect my child’s ability to participate in said program or associated activities.

Print ______Signature______Date______

Camper’s Name:______Relationship to Camper______

Fit & Fun Day Camp - Disciplinary Policies

It is our intention to provide your child with a safe and secure environment while at Fit & Fun Day Camp. We attempt to create a warm, comfortable, and fun atmosphere that will make your child look forward to coming to camp each day. In order to ensure the quality of this program and safety of our participants, each participant must follow program rules:

1)  Safety – Campers will refrain from crossing streets or parking lots without supervision, will cease behavior deemed unsafe when told to do so, and will follow rules of games and activities.

2)  Respect will be shown to all campers, staff, equipment, and property. Campers will cease to use equipment in ways deemed unsafe or damaging by staff, will not resort to name calling or other disrespectful behaviors towards anyone, and will clean up when asked to ensure continued enjoyment of equipment and facilities. Foul language will NOT be tolerated.

3)  Campers will keep hands, feet, head, and other body parts to themselves. Fighting, hitting, theft, destruction of property, etc, will NOT be tolerated. Physical violence will not be tolerated and may result in immediate suspension.

4)  Every camper has an important role in making the camp a success. Therefore cooperation and participation are expected from everyone. Reasonable measures will always be taken to ensure that every camper’s needs are met and are having fun, but disrupting the program to an detrimental degree will be addressed.

Fit & Fun Day Camp Five Point Policy

Whenever any of the above rules or other reasonable expectations are broken, the following Five Point Policy will be instituted:

1)  Verbal warning – Camper will be talked to about what they’re doing that isn’t in compliance with the rules and how to correct the behavior.

2)  Time Out/Activity Privilege Withheld – Camper will be removed from the area and will sit in a supervised location while camp continues for approximately 5 minutes. At that time, the camper will be allowed to resume play.

3)  1st Written Warning – An official warning will be sent home with parents detailing the event so parents can talk to child about it and attempt to resolve the issue. If behavior continues:

4)  2nd Written Warning – Parent/guardian will be notified to pick up camper immediately and camper will be suspended for the remainder of the day and 1 day following. If behavior persists:

5)  3rd Written Warning – Parent/guardian will be notified to pick up camper immediately and camper will be removed from the camp program and will not be eligible to return during the same season.

Each day, campers will start with a clean slate as for verbal warnings and time outs. Written warnings will reset at the end of each week unless a chronic behavior issue is identified. Cassandra will use her best judgment to decide what is to be done then and will discuss it with the parents.

Any issues, questions, or comments regarding the camp should be addressed with Cassandra immediately.

My signature verifies the following:

·  I have read and understand the above information and will ensure my child understands what is expected of them while at Fit & Fun Day Camp.

·  All information in this packet is true as of this date. I have disclosed all pertinent information.


Print ______Signature______Date______

Camper’s Name:______Relationship to Camper______