2010 Camper Intake Form

Camper’s Name ______

Age in June 2010 ______Birth Date ______

School or Play Group (if any) ______

Diagnosis (if any) ______

Please describe your child’s current hobbies or areas of interest______

______

Please list any activities, which your child has expressed, any apprehension regarding his/her participation ______

______

Has your child ever attended a(n): Day Camp program? No Yes

Describe significant successes or problem areas ______

______

What would you like your child to gain from his/her camp experience? ______

______

How does he/she feel about attending camp? ______

______

How does your child respond to new places, new situations and meeting new children and adults? ______

______

Does your child have any fears that we should know about?  No  Yes if yes, please describe ______

______

______

Please list any conditions, limitations and/or allergies (asthma, bee stings, food allergies, & motion sickness) ______

______

Description of child’s most recent diagnosis (if any) ______

______

______

Describe problems, if any, that your child may have with peers or adults? What techniques are the most successful in helping your child work through these problems?

Peers ______

Techniques ______

Adults ______

Techniques ______

Name of anyone other than the child’s parent who may pick up him/her from camp this summer

Name ______Relationship______Phone ______

Name ______Relationship______Phone ______

List food restrictions and special dietary needs ______

______

______

Any other comments you would like to share:

Parent Signature ______Date ______

CAMPER REGISTRATION SUMMER 2010

Camper Information

(Please Complete One Form per Child)

Camper’s Name______Nickname ______

Street Address______

City______State______Zip______

Gender M___F___ Birth date______

Family Information

Mother/Guardian ______E-Mail______

Address______Home Phone______

Work Phone______Cell Phone______

Father/ Guardian ______E-Mail______

Address______Home Phone______

Work Phone______Cell Phone______

Emergency Information

Emergency Contact #1______Emergency Contact #2______

Relationship ______Relationship ______

Home Phone______Home Phone______

Work Phone______Work Phone ______

Cell Phone______Cell Phone______

Billing Information – Tuition is $160.00 per weekly session. An extended day program is available for $210.00 per session. Payment is due in fullno later than June 1, 2010. Ten dollar, non-refundable registration fee is due with registration form. Fifty dollar non-refundable deposit is also due with registration form. This deposit will be applied toward tuition. If, for some reason, the camper is not accepted into camp (e.g. camp is full), the deposit will be returned in full. Checks should be made out to The Rayim Connection.

Payment By:

 Check #______ Paypal

I would like to enroll my child for the following weeks of summer camp (check all that apply):

Week # / Parsha / Theme / Dates
Week 1 / Balak; Numbers 22:2 - 25:9 / Animals on the farm / June 21-25
Week 2 / Pinchas; Numbers 25:10-30:1 / Count with me / June 28-July 2
Week 3 / Matot-Masei; Numbers 30:2-36:13 / What’s in a name? / July 5-9
Week 4 / Devarim; Deuteronomy 1:1-3:22 / Travel adventures / July 12-16
Week 5 / Vaetchanan; Deuteronomy 3:23-7:11 / From alef to tav / July 19-23
Week 6 / Eikev; Deuteronomy 7:12-11:25 / Israel our homeland / July 26-30
Week 7 / Re'eh; Deuteronomy 11:26-16:17 / Let’s be helpers / August 2-6
Week 8 / Shoftim; Deuteronomy 16:18-21:9 / My friends and I / August 9-13

Are you interested in the extended-day program (9:00 pm – 3:00 pm)? _____ Yes _____ No

$10.00 Registration fee ______Cash ______Check # ______Paypal

$50.00 Deposit ______Cash ______Check # ______Paypal

$25.00 Discount if registered for 3 or more weeks. ______

$5/week discount if registered before April 30, 2010. ______

$5/week sibling discount if registered before April 30, 2010. ______

Upon completing this registration I acknowledge that I have read and understand the Parent/ Guardian Consent form and that all information is true and correct.

Parent/Guardian Signature______Date______/______/______

To Register for Camp Rayim:

Fill out one Registration for each camper. Return forms with your $50.00 non-refundable deposit payment and $10.00 non-refundable registration free. Registration will be processed on a first come, first served basis. Registration will only be considered with completed application and deposit. Return campers need only return this page with deposit.

All payments must be made in full by June 1, 2010or paid in full if registered after this date.

There will be a $35.00 fee for returned checks.

POLICIES

Registration is available on a first-come first-served basis. If a camp reaches capacity, a waiting list will be developed.

Absences: There are NOrefunds or make up days for absences due to illness, vacation or other reasons.

Medical: Child Wellness form must be completely filled out and signed by a physician for children to attend camp.

Parent/Guardian Consent

  1. I request that the participant named above be admitted to CampRayim.
  2. I understand that the $50.00 deposit must accompany this form and that it is non-refundable and non-transferable unless my child is not accepted into the program. I further understand that the parent/guardian registering the above named child I, alone, am responsible for the fees as outlined on the front of this form. I further understand that if I withdraw my child from the program that I am responsible for the remaining balance of the fees.
  3. I understand that a medical form must be filled out, signed by the doctor and parent and returned before the first day of camp.
  4. I understand that the program participants may be asked to have a personal interview with the CampDirectors or designee.
  5. I have read and agree to abide the camp policies.
  6. I give permission for the above named participant to be included in camp photos and videos for publicity purposes in a variety of media, including but not limited to, brochures, advertisements and the Internet.
  7. I understand that the camp, its directors and/or staff shall not be responsible for loss of personal property or personal injury sustained by the participant and I hereby agree to indemnify and hold harmless the camp, its directors and/or staff from such losses or injury.
  8. In the event I cannot be reached in an emergency involving the above named participant, I hereby give permission to the appropriate medical personnel, selected by the CampDirector, to provide medical treatment deemed necessary by such medical personnel, including, but not limited to x-rays, tests, injection, blood transfusions, hospitalizations, anesthesia and surgery.
  9. I give my permission for the name, address, and phone number of the above named participant to be shared with the others on a written list.
  10. I hereby verify all information listed above is true and correct.
  11. I understand the policies as outlined on this registration.

Please include the following information with your registration form:

  • Copy of child’s most recent IEP (if applicable)
  • Copies of any current treatment goals (if applicable)

PROCEDURES

Children may be dropped off between 8:50 and 9:15 am.

Pick-up is between 12:50 and 1:10 pm or between 2:45 and 3:00 pm (extended day program)

Children should bring a dairy or pareve lunch and sippy cup (if needed) daily. Water, juice and healthy snacks will be provided.

Send diapers and wipes (if necessary), and a set of clothes (labeled) with your child the first day of camp.

Please do not send your child to camp if he or she is ill.

Emergency Medical and Liability Release Form

I, the undersigned, am the parent/legal guardian of ______, who is enrolled at the camp.

By signing this document, I confirm that:

  1. I wish to have my child registered in the CampRayimsummer camp and to have him/her participate in any activities during the program;
  2. I release the camp, it’s directors, teachers, employees and volunteers assisting during the camp sessions from any liability in connection with my child’s participation in any events and activities of the camp, which includes, without limitation, any liability related to an accident, an injury or illness suffered by my child;
  3. I authorize the camp and persons associated therewith to consent to medical treatment for my child, to select the medical personnel, hospitals and/or clinics to treat my child in case of any accident, injury or illness that may occur;
  4. In the event of an emergency, I authorize the camp to contact my child’s doctor, to administer first aid, to take my child to a clinic or hospital (emergency room) or to take any other action deemed necessary by the school or its employees.

Physician’s Name ______

Physician’s Address ______

Physician’s Phone Number ______

______

Signature of Parent or GuardianDate

Child Wellness Statement

To be completed by Child’s Physician

Child’s Name ______

Physician’s Name ______

Physician’s Address ______

______

Physician’s Phone Number ______

I, the undersigned, have examined the above-mentioned child in the last 12 months, and have found the child to be in good health and able to participate in all normal activities, including a day care or summer camp program.

______

Physician’s Signature Date

Camp Rayim Discipline and Guidance Policy

Discipline must be:

(1) Individualized and consistent for each child;

(2) Appropriate to the child’s level of understanding; and

(3) Directed toward teaching the child acceptable behavior and self-control.

A CampRayim caregiver may only use positive methods of discipline and guidance that encourage self-esteem, self-control, and self-direction, which include at least the following:

(1) Using praise and encouragement of good behavior instead of focusing only upon unacceptable behavior;

(2) Reminding a child of behavior expectations daily by using clear, positive statements;

(3) Redirecting behavior using positive statements; and

(4) Using brief supervised separation or time out from the group, when appropriate for the child’s age and development, which is limited to no more than one minute per year of the child’s age.

There will be no harsh, cruel, or unusual treatment of any child, for any reason. The following types of discipline and guidance are prohibited:

(1) Corporal punishment or threats of corporal punishment;

(2) Punishment associated with food, naps, or toilet training;

(3) Pinching, shaking, or biting a child;

(4) Hitting a child with a hand or instrument;

(5) Putting anything in or on a child’s mouth;

(6) Humiliating, ridiculing, rejecting, or yelling at a child;

(7) Subjecting a child to harsh, abusive, or profane language;

(8) Placing a child in a locked or dark room, bathroom, or closet with the door closed; and

(9) Requiring a child to remain silent or inactive for inappropriately long periods of time for the child’s age.

My signature verifies I have read and received a copy of this discipline and guidance policy.

______

Parent Signature Date

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