5 STAR KIDS CAMP 2018 REGISTRATION FORM
Camper Full Name: ______
Instructions: Complete and mail with fullpayment to 5 StarKids Camp, 1916 Bonifant Road, Silver Spring, MD 20906.
Date______
Camper Information
Nameof camper beingregistered:
Currenthome address of camper:
Summer address of camper(s)*:
*if different from above:
Summer address effective as of ( / / )
Grade camper just completed: ______Date of Birth: ____ / ____ / ______
Sex: Age: ______Weight______
School Name: ______
If a Camper did not attend a Maryland State Recognized school, a COMPLETE immunization record must be included or the camper WILL NOT be able to attend camp
Church Name (if applicable): ______
Other siblings also registering for Camp: ______
Please tell us how you heard about 5 Star Kids Camp: ______
Lunches are provided by the Maryland State Department of Education. All lunches, including those brought from home, must be stored in a refrigerator until consumed.
Parent/Guardian #1
Name______
relationship to camper(s)
Home phone # ______Cell phone #: ______
Work phone # ______Email address:______
*Street Address (if other than above): ______
Parent/Guardian #2
Name______
relationship to camper(s)
Home phone # ______Cell phone #:______
Work phone # ______Email address:______
*Street Address (if other than above):______
Emergency Contacts we may use if necessary:
#1 Name: ______Relationship:______Phone:______
#2 Name: ______Relationship:______Phone:______
Pick-up Permissions: Please list all person(s) who are allowed to pickup this camper from camp:
1. Name: ______Relationship to camper: ______
2. Name: ______Relationship to camper: ______
3. Name: ______Relationship to camper: ______
*Please list anyone who should specifically bepreventedfrom picking up this camper from camp and attach a brief note of explanation
Name: ______Relationship to camper: ______
Swimming Restrictions: (check one): ______Shallow end only ______Deep end permission*
*Note: Even if you grant Deep End permission for this camper they will still need to pass a swim testadministered
by camp staff and certified lifeguards at the designated pool.
Transportation Permissions:
5 Star Kids Camp has made every effort to provide responsible adults and a well maintained vehicle for your child to ride in.
I hereby consent to let my childparticipate in the swimming on (circle all that apply): Friday June 22 (week 1), Friday June 29 (week 2), Friday July 6 (week 3), Friday July 13 (week 4), FridayJuly 20 (week 5), Friday July 27 (week 6), Friday August 3 (week 7), Friday August 10 (week 8).
I grant permission for my child to be transported to the pool in the camp van. It is understood that every precaution will be taken for the safety and well-being of my child, but in the event of accident or sickness, 5 Star Kids Camp and its staff and volunteers are hereby released from any liability.
Signed:______Date:______
Medical Information: This medical section below is required by the MarylandDepartment of Health and Mental Hygiene, and must be completed fully.
Insurance Company: ______Policy #: ______
Name of Primary Care physician: ______Phone:______
** If camper is not a resident of Maryland or not attending a public or private school, complete immunizationrecords need to be attached along with this registration form.
List any foods or drinks the camper should not have:______
List any allergies:______(attach separate page if necessary)
List any medical conditions (physical, psychological, behavioral) that may hinder the camper from fully participating in all camp activities:______(attach separate page if necessary. An appointment with the camp nurse and director may be required.)
Will the camper need to take any medications at Camp? YES NO (circle one)
Note: If so, a medication form for self-administered medication will be provided for you to complete.
Dates of Attendance: Please circle the weeks of camp for which you wish to register this camper:
Tuition cost: $175 per child per week(Additional $15 admin. fee if not paid in full 7 days prior)
Week 1 June 18 – June 22
Week 2 June 25 – June 29
Week 3 July2 – July 6(No camp Tuesday, July 4th- Tuition $140)
Week 4 July 9 – July 13
Week 5 July 16 – July 20
Week 6 July 23 – July 27
Week 7 July30 – August 3
Week 8 August4–August 10
Extended Care: AM from 7:30-9am and / or PM from 4:00 – 5:30 pm
Before Care cost $30.00/week and After Care cost $30.00/week. Drop-in fee $10(0-30min.)
Extended care fees must be paid at the time of payment of weekly fees
Parents who pick up campers after 5:30 will be charged a $1.00 per camper, per minute late fee.
Week 1 AM Extended Care June 18 – June 22
Week 1 PM Extended Care June 18 – June22
Week 2 AM Extended CareJune 25 – June 29
Week 2 PM Extended Care June 25 – June 29
Week 3 AM Extended Care July2 – July 6 (No camp Tuesday, July 4th)
Week 3 PM Extended Care July2 – July 6 (No camp Tuesday, July 4th)
Week 4 AM Extended CareJuly 9 – July 13
Week 4 PM Extended CareJuly 9 – July 13
Week 5 AM Extended Care July 16 – July 20
Week 5 PM Extended Care July 16 – July 20
Week 6 AM Extended Care July 23 – July 27
Week 6 PM Extended Care July 23 – July 27
Week 7 AM Extended Care July 30 – August 3
Week 7 PM Extended Care July30 – August 3
Week 8 AM Extended Care August6–August 10
Week 8 PM Extended Care August6–August 10
Method of registration payment (check all that apply):
___ Cash
___ Check – Check number:______Name on account:______
**make checks payable to:“5 Star Kids Camp”
Medical Release Form
The parent/guardian approves of the camper’s participation and assumes all risks associated with participation in the program. 5 Star Kids Camp assumes no liability for injury or damages arising from participation in the program. Due to the strenuous nature of some activities, 5 Star Kids Camp encourages each participant to consult his or her physician concerning fitness to participate in the program.
I, the undersigned parent or legal guardian of ______, grant permission to Layhill Community Church and personnel acting on behalf of the 5 Star Kids Camp to approve any medical treatment needed to secure the welfare of the above named child. I understand that all medical costs will be assumed by our family and/or insurance program. I hereby release 5 Star Kids Camp of Silver Spring, MD, its staff and sponsors from responsibility and liability for any injury or illness my child may sustain from any liability during travel to, the duration of, travel home, and on any outings related to off- site trips. In case of an emergency, I hereby authorize an adult sponsor on trips, as agent for me, to consent to any X-ray exam, medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon, or dentist licensed to practice under the laws of the state wherein the service(s) are rendered, either at a doctor’s office, in any hospital, or location deemed advisable or necessary by any qualified physician. My son/daughter understands that he/she must follow the guidelines established by the Camp Director and approved sponsors. By signing here, I verify that all information on this form is correct and I agree with the release statement above.
______
Parent/Legal Guardian Signature Date
______
Witness Signature Date
Well Child Policy
Your child’s health is important to you and to those at 5 Star Kids Camp. We ask that you keep your child home if they have any of the following symptoms and/ or illnesses:persistent sneezing, persistent coughing, any discolored nasal discharge, lice, inflamed throat, earache, rashes/impetigo, runny nose and/or eyes, swollen glands, unusual fatigue or irritability, vomiting (within past 24 hours), stomachache, diarrhea, fever (over 99 degrees; must be fever free for 24 hours before returning to camp).
If your child is being treated with antibiotics, he/she must be on the drug for at least
24 hours before returning to camp.
PARENTAL CONSENT FORM
- I understand full tuition of $175 per child per week and any applicable before or after care payments must be included with this form. I understand that my child’s place IS NOT reserved until payment has been received in full.
- I understand that any payments submitted less than 7 days prior to my child’s scheduled week of attendance will be assessed a $15 per week administrative fee.
- I understand that any change or cancellation of registration is subject to a $15 per week administrative fee.
- I understand that if I pick up my child after 5:30 p.m., I will be charged a $1.00 per minute, per child late fee.
- I understand my child cannot begin any week of camp until the registration form isfully completed.
- I give permission for my child to participate in all camp activities, realizing that every safety precaution will be taken at all times but that 5 Star Kids Camp assumes no liability for injuries or damage resulting from regular participation.
- I give permission for the 5 Star Kids Camp staff and any agency acting on its behalf toprovide medical attention that might be necessary and urgent during a time when I cannot be contacted by telephone.
- I understand there will be a $30 fee for each returned check.
- I understand that camper registrations are accepted on a first-come, first-served basis. I will be promptly notified in the case I am placed on a waiting list and any monies paid will be refunded.
- I understand that medications can only be administered with a completed Physician’sMedication Order form signed by the prescribing doctor. This form will be provided once my registration is processed.
- I understand that the directors of 5 Star Kids Camp reserve the right to suspend anycamper for any length of time when it is deemed necessary in the best interest of the camper and/or the camp.
- I give permission for 5 Star Kids Camp to use my child’s name, voice, testimony, and/ordepictions in any type of promotional material.
- I understand that 5 Star Kids Camp cannot guarantee acceptance of this application. All applications are processed in order of arrival.
By signing my name, I indicate that I have read and understood the information contained within this registration form.
Parent/Guardian Signature Date
5 Star Kids Camp
1916 Bonifant Road, Silver Spring, MD 20906
Phone 301-310-5044 Fax 301-460-0113
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