Susannawesleyschool-Age Programs

SusannaWesleySchool-Age Programs

7433SW 29thSt. Topeka, KS66614

785-478-3703

EnrollmentApplicationforSummerCamp2017

~PersonalInformation~

Camper’sName: Sex: DateofBirth:

StartDate:DaysAttending:_ __ HoursAttending:

Address: Phone:

Street City ZipCode

Mother/Guardian: HomePhone: CellPhone:

HomeAddress:

Street City ZipCode

HomeE-MailAddress:

Occupation: PlaceofEmployment: WorkPhone: _

WorkAddress: _

Street City ZipCode

WorkE-MailAddress:_

Father/Guardian: HomePhone: CellPhone:

HomeAddress: _

Street City ZipCode

HomeE-MailAddress:

Occupation: PlaceofEmployment: WorkPhone:

WorkAddress:

Street City ZipCode

WorkE-MailAddress:

~E-MailAddress~

Pleaselistane-mailaddress(s)thatyouwouldlikeustouseforcorrespondence:

~PublicityRelease~

Igrantpermission for mycampertobeinvolved inpublicityforSusannaWesleySummer Camp Program,which mayinclude:

(Pleasecheckanyorallofthoseyouconsentto): ForCenterUseOnly Other

Audio/VisualRecording Television

PhotographsforPictureCD Newspaper

~ MedicalConditions~

Doesyourcamperhaveanydrug,food,orpetallergiesoris thereanythingelsewe shouldbe awareof:

~LocalEmergencyPick-UpList~

Person(s)allowedtopickup yourcamperwithparentalconsent,orto contactin caseofinabilitytolocateparent(s):

1. Name: Relationship:

Address: City: _Zip:

HomePhone: WorkPhone: CellPhone:

2. Name: Relationship:

Address: City: Zip:

HomePhone: WorkPhone: CellPhone:

~ DoctorandHospitalInformation~

NameofDoctor:

Address: City: Zip:

PhoneNumber:

NameofHospitalPreferenceincaseofemergency:

HealthInsurancePolicyName: PolicyNumber:

~Sunscreen/BugSpray~

ParentsaretoprovideSunscreenorBugSprayfortheirchild,andpleasemakesureyourchild’s nameiswrittensomewhereonthebottle. For bug spray a short-term medication form must be on file before we can apply.

Icertifythatallinformationonthisenrollmentformiscorrect:

ParentSignature: Date:

Anon-refundableone-timeactivityfeeof$145mustaccompanythisapplication.

Howdidyouhearaboutus?

CapitalJournal _Friend _PhoneBook/whichone

_SherwoodGazette _Mother ChildMagazine _SignOutFront

CCL.358 KansasDepartmentof HealthandEnvironment

Rev.1/2014 Bureauof FamilyHealth

ChildCareLicensingProgram

1000SWJackson,Suite200

Topeka,KS 66612-1274

Phone:(785)296-1270 Fax(785)296-0803

Website:

HEALTHHISTORYFORCHILDRENANDYOUTHATTENDINGSCHOOLAGE PROGRAMS

AsrequiredbyK.A.R.28-4-590(d) (1),eachoperator shallobtainahealthhistoryforeachchildoryouth,onaformsuppliedbythe department orapprovedby thesecretary. Eachhealthhistory istobemaintained inthechild’soryouth’sfileonthepremises. As requiredbyK.A.R.28-4-590(d)(2),eachoperatorshallrequirethateachchildoryouthattendingtheprogramhas currentimmunizations as specifiedinK.A.R.28-1-20orhasanexemptionforreligiousormedicalreasons.

CompleteoneformforeachchildoryouthattendingtheSchoolAgeProgram.

05/30/2017

FirstandLastNameoftheChild’sorYouth’sMotherorGuardian

Mother/Guardian’sHomeStreetAddress / City / ZipCode / HomePhone#
( )
Mother/Guardian’sWorkPlaceNameStreetAddress / City / ZipCode / WorkPhone# ( )

FirstandLastNameoftheChild’sorYouth’sFatherorGuardian

Father/Guardian’sHomeStreetAddress / City / ZipCode / HomePhone#
( )
Father/Guardian’sWorkPlaceNameStreetAddress / City / ZipCode / WorkPhone# ( )

NamesandagesofotherchildrenintheChildor Youth’sFamily(Attachadditionalpageif needed.)

Person(s)authorizedtopickup theChildor Youthin
caseofemergency.Includefirstand last nameand
StreetAddress.Attachadditionalpageifneeded.
1. / City / ZipCode / PhoneNumber(during
programhours):
2.
3.
Firstand LastNameof PhysicianStreetAddress / City / ZipCode / PhoneNumber
( )

NameofHospitalPreferencein caseof emergency.

Yes / No / N/A / Completethefollowinginformationaboutmedicationsfor thischildoryouth.
Willthis childoryouthneedto takeanynonprescriptionorprescriptionmedicationduringtheirtimeat the
program?
If yesabove,istheresignedpermissiononfile?
Circleanyofthefollowingconditionsordifficultiesthataffectthis childoryouth.
Allergies / Frequentsorethroats/colds / EarInfectionsorAches / HeartorLungConditions
SkinProblems / Asthma / Headaches / Diabetes
Vision / Speech/Communication / Hearing / Emotion/Behavior
Other:Pleasedescribe.

Ifyoucircledanyoftheaboveconditions,pleaseprovideadditionalinformationthatwillhelpthestaffmembersmeetthe child’soryouth’sneedswhileattendingtheprogram.(Attachadditionalpage,if needed.)

Provideadditionalinformationaboutyourchildoryouththatmightaffecthim/herwhileatthe SchoolAgeProgram includinganyspecialneeds,restrictionsto activities,majorchangesathomeorspecialinstructions.(Attachadditional page,ifneeded.

Completethefollowinginformationaboutthischild’soryouth’simmunizationstatus.

PleasegivedatesinthespacebelowforALLimmunizationseriescompletedbythischildoryouth.RecordMM/DD/YYYY.

1 / 2 / 3 / 4 / 5
DPT,DT*,TD(*DTonlyif childisallergicto DTP) / / /
/ /
/ /
/ / / / /
/ /
/ /
/ / / / /
/ / / / /
/ / / / /
POLIO
MMR
Single Dose Only / RUBEOLA(MEASLES)
MUMPS / / / / / /
RUBELLA(GERMANMEASLES) / / /
/ /
/ /
/ / / / /
/ /
/ /
HIB(HemophilusInflu.B) *RECOMMENDED / / /
/ / / / /
HBV(HepatitisB Vaccine) *RECOMMENDED
VAR(Varicella-ChickenPox) *RECOMMENDED

PrinttheFirstandLastNameofthePersonCompletingthisHealthHistoryform Relationshiptothe

Child/Youth

DateCompleted

IftheHealth Historyformwascompletedbya personotherthanaParent/Guardian, whoprovidedyouwiththisinformation?

Whatis thatperson’srelationshipto thechild/youth?

I attest,underpenaltyofperjury,thatto thebestofmyknowledge,the informationprovidedon thisformis true andcorrect. Signatureofpersoncompletingthisform DateSigned

CCL010 KansasDepartmentofHealthandEnvironment

Rev.8/2013 Bureauof FamilyHealth

1000SWJackson,Suite200

Topeka,KS 66612-1274

ChildCareProgram: (785)296-1270 Fax:(785)296-0803

FosterCareProgram:(785)296-1270 Fax:(785)296-7025

Website:

AUTHORIZATIONFOREMERGENCYMEDICALCARE

Writtenpermissionforemergencymedicaltreatmentmustbe on fileatthefacility.Consultwith thelocalemergencymedical facilityto be surethisform is acceptable.ReferenceK.A.R.28-4-127(b)(1)(A).School AgeProgramsreferenceK.A.R.28-4-

582(e)(2).

Nameoffacilityexactlyasstatedon thelicense. License#

Susanna Wesley School Age South0057315-009

I herebyauthorize JERRY MICHAEL (Nameof individual/staffmember)and/or

SWCC STAFF (Nameof individual/staffmember)whois(are)representative(s)of the

abovenamedfacilitytogiveconsentforanyandallnecessaryemergencymedicalcareformychildoryouth

(FirstandLastNameof ChildorYouth)whilesaidchildor youthisin saidfacility’s

custodybetweenthedates of 05/30/2017 and 08/11/2017 .

MM/DD/YYYY MM/DD/YYYY

SignatureofParentorGuardian DateSigned

Witnessto Parent’sorGuardian’ssignatureif requiredbythelocalhospitalorclinic. DateSigned

NotarizationofParent’sorGuardian’ssignatureifrequiredbylocalhospitalorclinic.

Stateof Kansas

Countyof _

Signedorattestedbeforemeon

(Seal,ifany.)

by . MM/DD/YYYY NameofPerson

_ Signatureof notarialofficer

Title(andRank)

Myappointmentexpires:

------

Listanyknownallergiesorotherinformationaboutthemedicalstatusofthischildoryouthpertinentin caseofemergency:

Is childcoveredbyhealthinsurance?YesNo

Ifyes, completethefollowing:

HealthInsurancePolicyName Policy Number MedicalAssistanceProgram CardNumber

MilitaryMedicalCareI.D.Number

Ifknown,dateoflastTetanusinoculation:

THEMEDICALRECORD/ASSESSMENTFORM(ORHEALTH STATUS HISTORYFORMFORSCHOOLAGEPROGRAMS)ANDTHE AUTHORIZATIONFOREMERGENCYMEDICALCAREMUSTBETAKENTOTHEEMERGENCYROOM. BOTHFORMSMUST ALSOBE INAVEHICLEWHENTHECHILDORYOUTHISTRANSPORTEDBY THEFACILITY.

SusannaWesleySchool-AgePrograms

SummerCamp2017ContractforFees

I, ,contractforservicesoftheSusannaWesleySummerCampProgram

(parent) formyCamperasspecifiedbelow:

Address: Gradeinfall2017: City: State: Zip: DaytimePhone: HomePhone:

CamperName: Grade(fall2017): Rate$ T-ShirtSize: CamperName: Grade(fall2017): Rate$ T-ShirtSize:

CamperName: Grade(fall2017): Rate$ T-ShirtSize:

Mycamper(s)willattendon thefollowingdays: M T W Th F

Duringthehoursof: AMArrival: PMDeparture:

Activityfeeis$145 perchildandcoversallfieldtrips.Thisisnon-refundable.

**FullTimeFeeis$1485foreleven weekswhichcanbe paid

in weeklyinstallmentsof $135/week

Noearlywithdrawalsallowed.**

Pleasereadcarefully:

AdditionalFee Information:

Late Departure Fees:It isthe SummerCamps policy tocharge anadditional fee forlate pick up. Chargesare$3per minute withno grace period.

Thisfee ispayablethe night oftheoccurrenceor the followingmorning. If fee isnotpaidthe camper will not be allowedto return until it ispaid.

ReturnCheckFee:Thecenter’spolicy isto charge afeeof $40.00 for returned checks. Aftertworeturned checks, cash ormoneyorder will be requiredfor payment.

LatePayment:Checksaredue each Friday for the upcoming weekof care.At 6:00pm onMonday, paymentsthathave not been received are subject toa$5.00late fee, and care will be suspended until account ispaid in full. Failure to payfeesmay result in immediate termination of summer camp services.

Bysigningthiscontract,

 IacknowledgethatIhavereadtheSusannaWesleySummerCampHandbookpostedontheSusannaWesley

UnitedMethodistChurch’swebsite(

 Ihavereadthiscontract and agreeto paytheabovestatedtuitionandanyotherfeesthatI mayincur.

 IagreetocompletetheEnrollmentFormandContractandreturnthemtotheofficenolaterthan1stdayofcarewiththe understandingthatuntilthesetwoformsalongwithactivityfeepaymentof$145.00areturnedinmychild

isnotenrolledinsummercamp.Rememberchildrenareenrolledonafirstcomefirstservedbasis.

 IunderstandthatIamtokeepSusannaWesleyupdatedonanychangestomyEnrollmentApplicationand/ormy

Contract.

IalsounderstandthatanychangeinenrollmentmustbeapprovedbytheAdministratorandmustbeaccompaniedbya newEnrollment/ContractforFeesform.Anychangein enrollmentrequiresatwo-weekwrittennoticeregardlessof camper’sattendance.Remainingtuitionpaymentforthesummerwillneedtobegivenattimeofnotice. SusannaWesleyreservestherighttoterminatethiscontractatanytimeandforanyreason.Nochangestothefee schedulewillbeapprovedpriortothecompletionofthisform.

IunderstandthatonceIsignandreturnthisagreementIamobligatedtopay theentireamountof$1485.00. Weeklyinstallmentsareavailable.Noreimbursements/creditsfor sick,unusedtimeand/orvacationwillbegiven.If camperiswithdrawnbeforetheendofthecamp(08/11/17)anyremainingbalancesmustbepaidinfullattimeof withdrawal.IindemnifyandsaveSWCCand itsemployeesharmlessfromanyliabilityormedicalpaymentsresulting frommychild’sparticipationinthissummercamp.

THESUMMERCAMPRESERVESTHERIGHTTO INCREASEFEESUPON30-DAYNOTICE.

Mother’ssignature Date

Father’ssignature Date