Jefferson Summer Camp 2019 Participant Information Survey

This online form is required to be filled out, in its entirety, for every child attending camp this summer, regardless of whether they have attended in the past. We must have this form and immunization records no later than May 20.

Question Title

* Your Child

Child's First Name

Child's Last Name

Child's Preferred Name (if different)

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* Child's Gender

Male

Female

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* Child's Date of Birth

Month (MM)

Day (DD)

Year (YYYY)

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* Child's Incoming Grade (as of September 2019)

Pre-K

Other (please specify)

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* Child's School (as of September 2019)

Edison Elementary

Franklin Elementary

Franklin Middle

Holmes Elementary

Hoover Elementary

Hoover Middle

Lindbergh Elementary

St. Amelia

St. John the Baptist

St. Christopher

Charter School for Applied Technologies

Glendale Elementary

Other (please specify)

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* Child's Primary Address

Address

City/Town

State

Zip

Phone Number

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* Child's T-Shirt Size

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XL

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* Who resides in the household where the child lives? Check all that apply.

Mother

Father

Guardian

Grandparent

Sibling

Other (please specify)

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* Primary Parent/Guardian

First Name

Last Name

Address

City/Town

State

Zip

Cell Phone Number

Email Address

Employer

Work Phone Number

Question Title

* Secondary Parent/Guardian (if applicable)

First Name

Last Name

Address

City/Town

State

Zip

Cell Phone Number

Email Address

Employer

Work Phone Number

Please list AT LEAST two people (other than the parent/guardians listed above) to contact in case of an emergency if a parent
cannot be reached. These individuals will also be authorized to pick-up your child.

Question Title

* Emergency Contact / Authorized Person To Pick Up My Child #1

First Name

Last Name

Relationship to Child

Phone Number

Alternate Phone Number

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* Emergency Contact / Authorized Person To Pick Up My Child #2

First Name

Last Name

Relationship to Child

Phone Number

Alternate Phone Number

Question Title

* Emergency Contact / Authorized Person To Pick Up My Child #3 (optional)

First Name

Last Name

Relationship to Child

Phone Number

Alternate Phone Number

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* Emergency Contact / Authorized Person To Pick Up My Child #4 (optional)

First Name

Last Name

Relationship to Child

Phone Number

Alternate Phone Number

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* Emergency Contact / Authorized Person To Pick Up My Child #5 (optional)

First Name

Last Name

Relationship to Child

Phone Number

Alternate Phone Number

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* Emergency Contact / Authorized Person To Pick Up My Child #6 (optional)

First Name

Last Name

Relationship to Child

Phone Number

Alternate Phone Number

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* Emergency Care

Physician Name

Physician Phone Number

Dentist Name

Dentist Phone Number

Preferred Hospital

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* Does your child require staff supervision at more than a 10:1 ratio to safely participate in our program?

Yes

If yes, please explain

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* Does your child receive special services (IEP, 504, Speech, OT, PT) in any other settings (school, home, other) currently or in the past?

Yes

If yes, please explain

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* Will your child be able to transition successfully between activities and participate in group play?

Yes

If no, please explain

Question Title

* Please select any allergies or food allergies/restrictions your child has? (i.e.- peanut allergy, vegetarian, etc.)

None

Vegetarian

Vegan

Gluten Free

Nut Allergy

Dairy Allergy

Bee Stings

Other

Please explain what allergy and what actions to be taken in event of an allergic reaction:

Question Title

* Does your child take any medications or have any medical conditions we should be aware of?

Yes

If yes, please explain

If your child will be bringing medication to camp, please fill out information below and bring your child’s medication in its original packaging in a clear, labeled plastic bag along with written doctor’s instructions for administration during camp hours. Our Health Director will be responsible for administering your child’s medication as per instructions from his or her doctor.

Children with allergies, seizure disorders, diabetes, or any other chronic health condition must submit a current action plan to Jefferson to have on file, in case of emergency.

Question Title

* Medication

Medication

Dosage

Times

Comments/Side Effects

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* Please let us know about any recent surgery or serious injury (type & date)

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* Chronic or recurring illness, condition, or diet

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* Does your child have any restrictions on activity?

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* Is there other information that our staff should be aware of that would make your child's participation at camp successful?

Yes

If yes, please explain

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* What days of the week do you anticipate your child attending camp?

Monday

Tuesday

Wednesday

Thursday

Friday

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* What weeks do you anticipate your child attending?

Week 1: July 1-5

Week 2: July 8-12

Week 3: July 15-19

Week 4: July 22-26

Week 5: July 29-August 2

Week 6: August 5-9

Week 7: August 12-16

Week 8: August 19-23

Comments (optional)

Question Title

* What time do you anticipate dropping your child off in the morning?

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* What time do you anticipate picking your child up in the afternoon?

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* Assess your child's swimming abilities

Non-Swimmer (unable to swim/no swim instruction)

Beginner Swimmer (some limited swim instruction)

Intermediate Swimmer (average swim ability)

Advanced Swimmer (skilled swimmer)

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* Has your child participated in a program like this before?

Yes

If yes, please explain reason for leaving

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* How did you hear about our summer camp?

Family member/friend

TTYPR website

Social media

Flyer from school

TTYPR e-newsletter

Live nearby

Newspaper

Have attended in the past

Other (please specify)

Question Title

* What are the top factors influencing your decision to send your child tosummer camp at Jefferson?

Cost

Location

Activities (field trips, swimming, sports, etc.)

Hours

His/her friends attend

Other (please specify)

If your child is 10 or 11 years old this summer, they may be eligible to participate in a "Counselor in Training" program during camp! If interested, please have him or her answer the questions below.

Question Title

* What is a leader? What leadership qualities do you have?

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* What area would you prefer to be stationed in? Rank from top choice (1) to bottom (5)

Art

Sports/Group Games

With a group/as a junior group counselor

Enrichment

Funland

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* Your Child

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* Child's Gender

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* Child's Date of Birth

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* Child's Incoming Grade (as of September 2019)

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* Child's School (as of September 2019)

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* Child's Primary Address

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* Child's T-Shirt Size

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* Who resides in the household where the child lives? Check all that apply.

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* Primary Parent/Guardian

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* Secondary Parent/Guardian (if applicable)

Question Title

* Emergency Contact / Authorized Person To Pick Up My Child #1

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* Emergency Contact / Authorized Person To Pick Up My Child #2

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* Emergency Contact / Authorized Person To Pick Up My Child #3 (optional)

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* Emergency Contact / Authorized Person To Pick Up My Child #4 (optional)

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* Emergency Contact / Authorized Person To Pick Up My Child #5 (optional)

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* Emergency Contact / Authorized Person To Pick Up My Child #6 (optional)

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* Emergency Care

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* Does your child require staff supervision at more than a 10:1 ratio to safely participate in our program?

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* Does your child receive special services (IEP, 504, Speech, OT, PT) in any other settings (school, home, other) currently or in the past?

Question Title

* Will your child be able to transition successfully between activities and participate in group play?

Question Title

* Please select any allergies or food allergies/restrictions your child has? (i.e.- peanut allergy, vegetarian, etc.)

Question Title

* Does your child take any medications or have any medical conditions we should be aware of?

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* Medication

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* Please let us know about any recent surgery or serious injury (type & date)

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* Chronic or recurring illness, condition, or diet

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* Does your child have any restrictions on activity?

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* Is there other information that our staff should be aware of that would make your child's participation at camp successful?

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* What days of the week do you anticipate your child attending camp?

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* What weeks do you anticipate your child attending?

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* What time do you anticipate dropping your child off in the morning?

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* What time do you anticipate picking your child up in the afternoon?

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* Assess your child's swimming abilities

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* Has your child participated in a program like this before?

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* How did you hear about our summer camp?

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* What are the top factors influencing your decision to send your child tosummer camp at Jefferson?

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* What is a leader? What leadership qualities do you have?

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* What area would you prefer to be stationed in? Rank from top choice (1) to bottom (5)

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* List any extracurriculars, hobbies, or skills you may have

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* How many years have you attended camp?

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* Why do you want to be a CIT?