Thank you for your interest in Camp Fire North Shore’s before and after school programs!
Our after school program runs daily when school is in session, from dismissal until 6:00. It includes age appropriate activities such as homework club, arts & crafts, sports, games, and outdoor play. Before school care at Shoemaker runs from 7:00 am until school starts. Our after school program is a flat rate of $20 per day and our before school program is a flat rate of $7 per day.
Before your child begins the program, we want to share some information with youand provide you with the forms (pages that follow) that need to be completed and returned to Camp Fire:
- Registration forms – This includes registration forms, health history, and transportation plan.
- Parent contract – This indicates your agreement to policies (including paying one week in advance and giving a two-week notice for termination or permanent schedule changes), enrollment days, and weekly payment amount. Don’t forget to initial the bottom for the media release!
- Homework contract -This lets staff know what you expect your child to do during after school homework time.
- Bullying contract - This needs to be signed by BOTH parent AND child. At Camp Fire we have a zero tolerance bullying policy and teach our kids to be respectful and kind.
- Walking field trip permission slip–Signing this form allows Camp Fire staff to walk your child(ren) to the park or other nearby locations throughout the school year.
- Automatic payment form –If you would like to have your weekly tuition fee automatically deducted, please download this form from Camp Fire’s website and return it to the office. Site Coordinators CANNOT accept this form at school. As a reminder, payment is due each Monday for the following week, and this is a great way to make sure you don’t forget!
Please return these forms to Camp Fire’s office, 2 Cain Road, Salem, MA 01970as soon as possible. You can mail, drop off, email them to , or fax them to 978-745-1385. Your child is NOT enrolled until we have received all forms and payment.
We have also posted our Parent Handbook and Health Care Policy Handbook online at Please be sure to read through it, as some of our policies have changed/been updated this year. If you want a printed copy, please let us know and we can provide it at your child’s site.
We are looking forward to serving you and your child(ren) this year and are eager to make the time spent in our extended day school programs fun and enriching. If you have any additional questions or comments, please call me anytime at (978) 745-7200.
Sincerely,
Kerry Salvo
Program Administrator
Welcome to Camp Fire North Shore’s
Extended Day School programs!
To help serve you better here are a few reminders:
- Payment is due the MONDAY before the week your child attends. You can mail it to 2 Cain Road, Salem, MA 01970, drop it off in our mail slot, or pay by credit card over the phone. We can also set up weekly automatic pay (see enclosed form).
- We will be going outside every day (weather permitting), so please send your child(ren) with proper attire depending on the forecast/time of year.
- Our programs open at 7:00 am and close at 6:00 pm. Please do not drop your child off prior to 7:00 am, as there will be no staff on duty. If you pick up late, you will be charged a late fee of $10.00 per every fifteen minutes after 6:00 pm. This late fee will be reflected in your balance due the following week.
- It is a requirement that you sign your child in (time and initials) and out (time and initials) each day. That means you will need to come inside to do so.
- If there are any changes in your contact information, days your child needs to attend, or if you need to cancel enrollment, please keep us informed by calling the main office at 978-745-7200. We require a two-week notice prior to cancelling or you will be financially responsible for the payment.
- We will ask for identification for anyone picking up your child. Please come prepared and if other authorized individuals are picking up, let them know to bring ID.
- We offer a healthy snack daily, but if your child needs more snacks please send extras.
- We follow the Lynn Public Schools calendar. If school is closed for a holiday or vacation, we do not run program and do not charge a fee. We do charge for the first three snow days.
- Electronics are not permitted at our programs. This includes: video games, IPods, phones, cameras, MP3 players, personal toys, etc. They are distracting and we don’t want them to get lost, broken or stolen. If your child brings them to the program, they will be asked to keep them in their bags or a staff member can hold onto them.
If you have any questions, please feel free to ask any time. The main office number is 978-745-7200 and the Director’s email is . We look forward to serving you during the 2016-2017 school year!
Camp Fire Extended Day Program School Sites Phone Numbers
ABORN781-771-4122
409 Eastern Avenue, Lynn (located in bottom floor classroom)
BRICKETT781-771-5245
123 Lewis Street, Lynn (located in bottom floor/cafeteria)
CALLAHAN781-732-0349
200 O’Callaghan Way, Lynn (located in gym/cafeteria)
HARRINGTON781-771-5649
21 Dexter Street, Lynn (located in cafeteria)
SHOEMAKER781-771-9220
26 Regina Street, Lynn (located in cafeteria)
SISSON & PICKERING781-771-6309
58 Conomo Street, Lynn (located in the Pickering cafeteria)
TRACY781-771-5490
35 Walnut St, Lynn (located in cafeteria)
2016-2017
CAMP FIRE EXTENDED DAY PROGRAMS
Youth REgistration / Health history FORM
YouthINFORMATION
Last Name: / First Name: / Middle: / Gender: M F / Age: / Birth date:
Street Address: / City: / State: / Zip: / Phone Number: / School: / Grade:
Demographic information is desired only for statistical purposes. Responses will not affect the applicant’s qualification to enroll.
Ethnic/Racial:
African-American Hispanic Caucasian
Native American Asian Other ______/ Total # in Family:
2 – 3 4 – 5
6 – 8 Over 8 / Household Income:
under $15,000 $35,001 - $45,000
$15,001 - $25,000 $45,000 - $55,000
$25,001 - $35,000 over $55,000
Disabilities:
Physical:______
Developmental:______/ Other: ______
______
Parent / Guardian Information
Parent / Guardian Name: / Primary Phone: Secondary Phone: / Address if different from child:Parent / Guardian Name: / Primary Phone: Secondary Phone: / Address if different from child:
Persons authorized to pick up my child: Name & Relationship: Name & Relationship:
Persons NOT authorized Name & Relationship: Name & Relationship:
to pick up my child:
IN CASE OF EMERGENCY
Name of local friend or relative (not living at sameaddress): / Relationship to youth: / Primary Phone: / Secondary Phone:
Name of local friend or relative (not living at same address): / Relationship to youth: / Primary Phone: / Secondary Phone:
Medical Information
List of activities my child cannot participate in: ______
List any allergies or physical/health limitations:______
______
Medications: ______
Youth Health History - Please indicate Yes or No on each line:
Frequent Colds: ______
Frequent Sore Throats:______
Heart Trouble: ______
Convulsions:______
Abscessed Ears: ______
Athlete’s Foot: ______
Fractures:______
Fainting:______
Stomach Upset:______
Constipation: ______
Diabetes: ______
Rheumatic Fever: ______
Tuberculosis: ______
Kidney Trouble: ______
Chicken Pox:______
Measles: ______
Sinusitis:______
Mumps:______
Poliomyelitis:______
Whooping Cough:______
Hay Fever: ______
Skin Allergies:______
Bronchitis: ______
Serious Ivy or Oak:______
Poisoning:______
Other:______
The Commonwealth of Massachusetts
Department of Early Education and Care
Child’s Enrollment Form
Child Information
Child’s Name:______Date of Birth:______
Age at Admission:______Date of Admission:______
Child’s Home Address:______
Home Phone Number:______
Primary Language:______Identifying Marks:______
Eye Color:______Hair Color:______Skin Color:______
Sex:______Height:______Weight:______
Parent/Guardian Information
Parent/Guardian 1 Name: ______
Relationship to Child:______
Home Address:______
Reachable Phone Number:______
Email Address:______
Business Name:______
Business Address:______
Business Phone Number:______
Hours at Work:______
Parent/Guardian 2 Name:______
Relationship to Child:______
Home Address:______
Reachable Phone Number:______
Email Address:______
Business Name:______
Business Address:______
Business Phone Number:______
Hours at Work:______
Additional Information
Child’s Physician:______
Address:______Phone Number:______
Allergies/Special Diets?______
Individual Health Plan for child with a chronic health condition? If yes, please attach.______
Copies of any custody agreements, court orders, and restraining orders pertaining to the child? If yes, please attach.______
Special limitations or concerns? ______
______
School Age Only
Current School:______
School Address:______School Phone Number:______
I certify that documentation of physical examination and immunizations in accordance with public school health requirements and lead poisoning screening in accordance with public health requirements are on file at my child’s school. Parent/Guardian initials:
______
Parent/Guardian Signature Date
THE COMMONWEALTH OF MASSACHUSETTS
Department of Early Education and Care
FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM
Child's Name: ______Date of Birth: ______
I authorize staff in the child care program who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate.
I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and/or to ______, and to secure necessary medical treatment for my child.
Child's Physician Name: ______
Address: ______
Phone Number: ______
Child's Allergies: ______
Chronic Health Conditions: ______
Emergency Contacts (In order to be contacted)
Name______
Address______Relationship to child______
Home Phone______Cell Phone______
Do you give permission for child to be released to this person? Yes_____ No______
Name______
Address______
Relationship to child______
Home Phone______Cell Phone______
Do you give permission for child to be released to this person? Yes_____ No_____
Name______
Address______
Relationship to child______
Home Phone______Cell Phone______
Do you give permission for child to be released to this person? Yes_____ No___
______
Parent /Guardian Signature Date (valid for one year)
THE COMMONWEALTH OF MASSACHUSETTS
Department of Early Education and Care
Small Group and Large Group Transportation Plan and Authorization
CHILD’S NAME:______
MY CHILD WILL ARRIVE AT THE PROGRAM:MY CHILD WILL DEPART FROM THE PROGRAM:
___PARENT DROP OFF___PARENT PICK UP
___SUPERVISED WALK___SUPERVISED WALK
___UNSUPERVISED WALK___UNSUPERVISED WALK
___PUBLIC/PRIVATE/VAN___PUBLIC/PRIVATE/VAN
___PROGRAM BUS/VAN___PROGRAM BUS/VAN
___CONTRACT/VAN___CONTRACT/VAN
___PRIVATE TRANS. ARRANGED BY PARENT___PRIVATE TRANS. ARRANGED BY PARENT
___OTHER___OTHER
I give permission for my child to be released from the program at the end of the program day as stated above and/or I give permission to the following people to receive my child at the end of the day. (If no one is authorized other than the parent/legal guardian, please indicate below “NO ONE.”)
If a child is protected by a restraining order please submit order to the provider.
Name______
Relationship______
Address______
Reachable Phone number (cell) ______
Name______
Relationship______
Address______
Reachable Phone number (cell) ______
Name______
Relationship______
Address______
Reachable Phone number (cell) ______
PARENT /GUARDIAN SIGNATURE______DATE______
REFER TO FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM FOR RELEASE INFORMATION
2016-2017
Camp Fire North Shore Extended Day Programs
Parent Contract 2016 - 2017
I, ______, am enrolling my child(ren)
Parent/Guardian
______in the Camp Fire North Shore Extended Day
Name(s)
Programs at a rate of $7.00 per day for before school care (at applicable schools) and $20.00 per
day for after school care. I am enrolling my child(ren) in the following [check all that apply]:
Before school: Mon_____Tues_____Weds_____Thurs_____Fri_____
(Only Shoemaker has a before school program in 2017)
After school: Mon_____Tues_____Weds_____Thurs_____Fri_____
Children can be enrolled in before school, after school, or both. A minimum of two days for each type of service you enroll in (morning or afternoon) is required.
The total weekly rate per child that I agree to pay is: $______until the last day of the 2016-2017 school year, unless two weeks notice in writing of termination from program OR request in PERMANENT change in the child’s schedule is submitted.
I enter into this contract with the full knowledge of my obligation and my agreement to meet the following policies of Camp Fire North Shore:
To complete a child registration packet and pay a non-refundable $20.00 per child / $30.00 per family annual registration fee. The registration packet must include all pertinent information related to the safety of my child and I agree to update all of the information as necessarythroughout the year. This includes changes in phone numbers, address, medical history, emergency contacts, etc.
To pay tuition the Monday before my child attends the program at the above rate whether or not my child is in attendance. This is a full week in advance. This includes when my child is out sick and vacation time when the program is open.
I will be required to pay a late fee of $10.00 per fifteen minutes if I do not pick up my child by the closing of the program. Continuous tardiness could result in termination of my child from the program.
I understand that I am not obligated to pay for scheduled holidays and school vacation days. I am responsible to pay for up to three snow days per year. I also understand that Early Release Days incur an additional charge of $5.00 per child and is due with that week’s tuition.
I further understand that if I fall behind in tuition payments, the Camp Fire Extended Day Programs will terminate my child’s participation in the program, effective immediately. This action will not alter my obligation to pay the balance due.
I agree to call the Camp Fire Office or the Camp Fire school site if my child will be out sick or is going to be absent.
I authorize Camp Fire North Shore to photograph/video my child while involved in after school activities. I understand these pictures will only be used for Camp Fire promotion, marketing and for after school projects. INITIALS _____
______
Parent/Guardian Signature Date
HOMEWORK CONTRACT
At this time, I do not wish for my child to participate in
Homework Clubat Camp Fire. S/he will complete homework at home.
I would like my child to participate in Homework Club at
Camp Fire. I have discussedthe Homework Contract with my child and filled out the information below.
Please take a minute to think about your wishes for your child during the Homework Club time. Talk with your child about how they feel about homework. Once you’ve decided what is best, please circle the items below that pertain to you and your child, and return to Camp Fire.
We have decided that will participate in
(child name)
Homework Club on: (please circle) MON TUES WED THURS FRI
During Homework Club, will:
(child name)
- Do a minimum of minutes of homework at Camp Fire.
- Get assistance with homework.
(subject area/s)
- Have their homework checked by a staff member.______
-OR-
- Parent(s) will review child’s homework at home. ______
I understand that homework is my responsibility and I will do my best to stay on task during Homework Club at CampFire. I have talked with my parents about how I like to do my homework, and we have made a plan together to help me with my homework. By signing this contract, I agree to come prepared to participate in Homework Club, bringing my books and other things I need to complete my work. My parents or a counselor will check over my work and I will make any corrections they suggest/request. I also agree to respect the rules of the Homework Club space, so that everyone has the opportunity to complete their work.
Child’s Signature ______Date______
Parent Signature ______Date______
Anti-Bullying Contract
Student and Parent/Guardian Agreement
Extended School Programs 2016-2017
Everyone has the right to feel physically and emotionally safe at the after school program. I will do everything I can personally, as a member of my school’s community, to create and preserve a physically and emotionally safe environment.
Student’s responsibility:
I commit that I will not bully my peers. When I witness bullying, I will report it to an adult and/or the bullying box.
______
Student’s NameGrade
______
Staff Member NameDate
Parent/Guardian’s responsibility:
I commit to encouraging my child to always respect others. I have instructed my child not to bully. I have advised my child to report any bullying to the staff. I will do everything I can personally, as a member of my school’s community, to create and preserve a physically and emotionally safe environment.
______
Parent/Guardian Signature Date
We understand that bullying will result in the following disciplinary action:
1st Offense: Name reported to staff member. Sign the behavior log.
2nd Offense: Name reported to staff member. Sign the behavior log, parental contact, and loss of privilege or free time.
3rd Offense: Name reported to staff member. Sign the behavior log, parental contact to be picked up from program.
4th Offense: Name reported to staff person. Sign the behavior log, parental contact to be picked up from the program. (Three times being picked up from the program in a school year will result in expulsion from program.)
Any severe situation by child or parent will result in a student being expelled from the program immediately.
CAMP FIRE NORTH SHORE
EXTENDED DAY SCHOOL PROGRAMS
I hereby give permission for my child to participate in supervised walking field trips (weather permitting) with members of the Camp Fire staff (to locations such as playground, field, park, etc.). Children will bring their belongings with them so they can be picked up at the off-site location.
Child’s Name:______
Parent/Guardian Signature:______
Date:______