9
SUMMER CAMP 2017 SCHOLARSHIP REGISTRATION FORM
TUESDAY - THURSDAY
9:00 a.m. – 2:00 p.m.
(No groups on Mondays or Fridays)
Location: Greenwood Community Church
5600 E. Belleview Ave., Greenwood Village, CO 80111
Week 1: LOST IN SPACE Week 2: FROZEN Week 3: SURF’S UP
Child’s Name / Date of Birth / Grade(Fall 2017) / Sessions
(Indicate all that apply)
1. / Week 1
Week 2
Week 3 / 6/27 – 6/29
7/3 – 7/6
7/11 – 7/13
2. / Week 1
Week 2
Week 3 / 6/27 – 6/29
7/3 – 7/6
7/11 – 7/13
3. / Week 1
Week 2
Week 3 / 6/27 – 6/29
7/3 – 7/6
7/11 – 7/13
(PRICES DECREASE WITH MULTIPLE WEEKS)
PRICING*
Regular Weekly Program Fee: $210.00 per camper/$190 for siblings
Scholarship Program Weekly Fee: $50.00 per camper
Participant(s) / # of Weeks / Total $ Per Child
1st child / $
Sibling 1 / $
Sibling 2 / $
Total: / $
* After March 31th, prices increase by $20 / Deposit of $50 per child AND
Enrollment Forms due:
April 15, 2017
**Balance due:
May 24, 2017
E-MAIL, MAIL or FAX FORMS TO:
E-mail:
Phone: 303-773-3960
Fax: 303-759-0803
Mail: Connect Us
6940 S. Holly Circle Suite #107
Centennial, CO 80112
**To arrange a payment schedule or for financial assistance, please call
us at 303-773-3960.
REGISTRATION FORM, PAGE 2
REGISTRATION DUE DATE: Completed and signed registration forms, along with a $50 deposit check or online payment per child, are due no later than April 15, 2017. Please make checks payable to Connect Us.
DEPOSIT: Deposits paid by check will be held until May 24, 2017. Deposits are refundable, less a $25 processing fee per child when we receive written notice of cancellation by May 24, 2017. After May 24, deposits are nonrefundable.
BALANCE DUE: Remaining balances are due no later than May 24, 2017.
CANCELLATIONS: Payments and deposits will be refunded in full, less a $25 processing fee, when written notice of cancellation is received by May 24, 2017. For cancellations occurring after May 24, 2017, Connect Us will refund the total amount paid less the $75, which includes $50 deposit and $25 processing fee.
There are no refunds for absences; however, in extenuating circumstances, such as hospitalization or a family emergency, we can credit the cost of missed days to our other programs.
If you would like to discuss payment plans or financial assistance, please call us at 303-773-3960.
All payments can be made with a personal check (payable to Connect Us) or online. Go to www.connectusnow.org and choose the “Programs” link on the top menu bar.
Payment options — select one:
О I have enclosed a check or cash for full payment in the amount of $______.
О I have enclosed a check or cash for deposit in the amount of $______.
О I have made an online payment of $______.
TERMS AND CONDITIONS
I request that my child be admitted to Connect Us Summer Camp. I have read and understand the Connect Us refund and cancellation policy.
Parent/Guardian: / Date:PARENT’S GUIDE TO CONNECT US SUMMER CAMP, PAGE 1
Payment/Cancellation Policies:
Registration Due Date:Completed registration forms, along with a $50 depositper weekper childaredue no later than May 24, 2017.
Deposit:Deposits are refundable, less a $25 processing fee per child when we receive written notice of cancellation by May 24, 2017. After May 24, deposits are nonrefundable.
Balance Due Date:Remaining balances are due no later than May 24, 2017.
Cancellations and Refunds:Payments and deposits will be refunded in full, less a $25 processing fee, when written notice of cancellation is received by May 24, 2017. For cancellations occurringafterMay 24,Connect Us will refund the total amount paid less the $75, which includes $50 deposit and $25 processing fee. There are no refunds for absences; however, in extenuating circumstances, such as hospitalization or a family emergency, we can credit the cost of missed days to our other programs.
If you would like to discuss payment plans or financial assistance, please call us at 303-773-3960.
All payments can be made with a personal check(payable to Connect Us)or online.Click onour summer camp page for theMAKE A PAYMENTlink.
General Camp Information
The following information will be emailed to families the week before camp begins.
Location and Drop-off/Pick Up:Drop off time: 8:50 a.m. Pick-up time: 2:00 p.m. ***There will be no supervision before 8:50 a.m. Pick up outside at 2:00 p.m. in the same location as drop off. On inclement weather days, pick up from classrooms.
Location: Greenwood Community Church, 5600 E. Belleview Ave, Greenwood Village 80111.
(Park in southwest corner of lot, walk east along the back of the building to meet staff.)
Contact During Camp Hours:If child/children will be absent, will be picked up late or you need to arrange an earlier pick up time, please call us at 303-773-3960 or email . If it’s critical that you speak with a staff member during camp hours and you’re unable to reach us at the number above, please call:
· ~Director Stephanie Schiff’s Cell: 303-807-1836
· ~Coordinator Shalin Zuther’s Cell: 303-653-6447
As a last resort, call Greenwood Community Church at 303-843-0281. To reach us outside of camp hours, please call 303-773-3960 or email .
Clothing and Other Items:
Bring First Day–
• Extra set of clothing in a labeled, zip-lock bag (recommended for younger children in case of accidents)
• Epi-pen, inhaler, special snacks for dietary restrictions, etc.—all labeled!
Wear / Bring Each Day–
• Play clothes-okay to get dirty or stained
• Sneakers
• Sunscreen-apply prior to arrival each day
• Swim suit & towel (on Water Day Wednesdays)
• Water bottle
• Lunch
PLEASE LABEL ALL ITEMS TO ENSURE THEY ARE RETURNED TO YOU!
Snack, Lunch and Birthday’s:Typical snack items served include fruit, pretzels, fruit snacks, popsicles, graham crackers and goldfish. If your child has food restrictions or allergies, be sure to indicate that on the Medical/Emergency Form. If you are providing your child’s snacks, please label with his/her name. If you’d like to contribute a specific snack to your child’s group, it will be received with gratitude!
Lunch: Children need to bring a lunch and water bottle from home each day. These items should also be labeled!
Birthdays: If your child’s birthday occurs during the session, we would love to celebrate it. If you’d like to provide a birthday snack for his/her group, please inform us. Again, we will provide treats for those with dietary restrictions.
Dietary Restrictions:We are pleased to be able to accommodate the needs of those campers with dietary restrictions by having certified gluten and dairy free snacks available. If your child has dietary restrictions, please indicate that on the MED FORM and whether or not you or Connect Us will be providing your child’s snacks.
Allergy Alert:We do not provide snacks with peanut butter, nuts or nut products. Some children have an allergy to nuts, a potentially life-threatening condition. If you provide a snack for your child’s group, please do not bring anything that contains nuts or nut products.
Medications, cardiopulmonary resuscitation (CPR):Connect Us staff will not administer any medication to a child unless it is an emergency, such as an allergic reaction that requires an Epi-pen.
Each program will have staff certified in CPR.
Many of our games involve physical activity. Children who are not feeling well should not attend camp. If a child tells us they don’t feel well, they will be asked to sit out of games and parent/guardian will be contacted to pick them up. In cases where parents have indicated a pattern of avoidance behaviors, we’ll determine with parents an appropriate approach to their anxiety prior to session.
Safety:The well-being of our participants is our first priority! Groups are staffed and structured to optimize safety and to ensure that every child is nurtured. Our facilitators actively promote an appreciation of personal and cultural differences and expect participants to treat others with kindness and respect. When a conflict occurs between children, we typically address it in the group; allowing children to work on communication and problem-solving skills.
Behavior:Connect Us programs are all about relationship-building, teamwork and the joy of group play. If a participant isn’t having fun or has a negative attitude, it can be detrimental to the group. Facilitators use a number of strategies to address this and other disruptive behaviors, however, they are not therapists. If behaviors persist, we may suggest that a written Behavior Agreement is implemented with the child. This strategy is highly effective when the same behavior expectations are reinforced at home.
If a child is aggressive toward other children or staff, or is repeatedly disruptive after adult intervention, it may be necessary to remove the child from the program. If we are unable to accommodate a child, we will refund the cost for days he/she did not attend. Connect Us reserves the right to dismiss a participant from our program if we are unable to meet the child’s needs.
Communication:At the end of each week, we will email a Weekly Recap which will include highlights and photos from the week and information pertinent to the following week. Parents/guardians are always welcome to speak with our staff at pick-up. If you’d like to discuss your child in greater depth, please call 303-773-3960 or email to schedule.
Your input is critical to our results! If at any time you have questions or concerns or would like us to reinforce anything you’re working on at home, please don’t hesitate to contact us.
Thank you for entrusting us with your child/children!
Parent/Guardian: / Date:MEDICAL/EMERGENCY INFO and RELEASE FORM
(Please fill out a separate form for each child)
Child’s Name / Birthdate / Grade / School / Primary contact’s name & phone #PARENT/GUARDIAN INFORMATION
Parent/Guardian: / Parent/Guardian:
Address: / Same Address
Address:
City/Zip: / City/Zip:
Home phone:
Cell:
Work: / Home phone:
Cell:
Work:
E-mail: / E-mail:
OTHER EMERGENCY CONTACT INFO
Friend/Relative (relationship to Child): / Physician:
Primary phone #: / Physician phone #:
Phone # 2:
List any medical conditions, including illnesses, surgeries, drug reactions or drug/food allergies, special diets, medications, diagnoses or any other concerns or information we should know about your child. You may continue on the back of this page.
PARENTAL CONSENT
As a parent or guardian of a child/children enrolled in a Connect Us program, I authorize the director or staff member(s) into whose care I have entrusted her/him/them permission to perform medical treatment for my child/children as needed. This includes my consent to have Connect Us transport my child/children to a licensed medical facility should the situation require it. I understand that in such a case, reasonable attempts would first be made to contact me or the contacts listed above, with time and conditions permitting. I have included, above or on an attached sheet, information about my child’s/children’s medical history and emergency contacts. I understand that each participant assumes all risks, consequences and potential liability. I hereby release and hold harmless the program site, director and staff members of Connect Us, its employees, volunteers and any other person, firm or corporation charged or chargeable with responsibility or liability from any and all claims by reason of accident, illness, injury or other consequences arising from participation in a Connect Us program.
My child has permission to:
· Participate in all sports and activities (List any exceptions): Yes No
· Eat snacks provided by Connect Us (List any exceptions): Yes No
· Eat gluten, dairy, wheat and soy free snacks (List any exceptions): Yes No
· Be photographed and videotaped for our website; for the purpose of evaluating our program, training our staff or for marketing materials: Yes No
I have carefully read this agreement and fully understand the contents. I am aware that this is a release of liability on behalf of my child and I sign it of my own free will.
PARENT/GUARDIAN SIGNATURE: / DATE:
AUTHORIZED TO PICK UP CHILD/CHILDREN
Child/Children: ______
Authorized Person / Relationship to child / Phone NumberIn addition to parent/guardian and emergency contact(s) listed on Medical/Emergency Form, the following people are authorized to pick up my child/children:
I understand that Connect Us will not release my child/children to anyone other than parent/guardian or individuals listed above, nor will Connect Us allow my child/children to leave the premises until they are released to an authorized person.
Parent/Guardian: / Date:
PARENT INTAKE QUESTIONNAIRE
(Please fill out a separate form for each child)
Today’s Date: / Completed By:Child’s Name: Sex: Birthdate: Grade:
(1) How did you learn about this program?
(2) What are your child’s favorite activities or interests?
(3) What are your child’s greatest strengths?What is most challenging for your child?
(4) Rate each sentence below from 1 to 4 as it relates to your child during unstructured play time, such as at recess or on a playground.
1=Never 2=Rarely 3=Occasionally 4=Frequently
a. ___ Decides what he/she wants to play and recruits peers to join in
b. ___ Joins in a sport, activity or game regardless of whom is playing
c. ___ Seeks out specific friends and plays whatever they are playing
d. ___ Plays alone
(5) Using the same scale in question 4, please rate your child on the following:SCALE
a. Initiates social interaction / 1 / 2 / 3 / 4
b. Maintains friendships / 1 / 2 / 3 / 4
c. Is cooperative (helpful, gets along with adults and peers) / 1 / 2 / 3 / 4
d. Is flexible (goes with the flow, willing to try new things) / 1 / 2 / 3 / 4
e. Is resilient (rebounds from disappointment, copes well with frustration) / 1 / 2 / 3 / 4
f. Is self-confident (positive about self and abilities) / 1 / 2 / 3 / 4
g. Is empathetic / 1 / 2 / 3 / 4
COMMENTS:
(6) What would you like your child to gain from participating in our program?