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 before you register. Only once you have completed this form will you be eligible to register for camp. Copies of immunization records and most recent physicals will be due as part of this process. Should your child be due for immunization(s) and/or a physical between the time of registration and the end of camp, you must submit updated records to us ASAP. We encourage you to register as soon as possible, but at least one week in advance (based on availability). We will not allow registrations less than one week in advance, regardless of space.

Filling this form out does NOT hold a spot for your child in our program! Your child's spot is not guaranteed until registration and payment are made. This is step one in the process.

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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 2021)

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* Child's School (as of September 2021)

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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)

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.

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* 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?

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

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

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

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 current 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 from their doctor to Jefferson to have on file, in case of emergency.

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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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* IF you would like to grant permission for your child to walk home from camp (ages 10+ only), please indicate which days this applies to and what time they should be released from camp. They will need to sign themselves out at the front desk. Should we need to discuss something with you, we may call you to come in/pick them up instead.

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* Depending on guidelines in place as camp gets closer, we may or may not offer field trips and/or swimming at Lincoln Pool as "a la carte" options (you would have to pay an additional fee on top of your weekly camp fee if you sign up for these). Please let us know, if it's an option, whether or not you would send your child on field trips/swimming trips.

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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 to summer camp at Jefferson?

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* Please tell us a little bit about your child (likes, dislikes, hobbies, personality traits) - we can pass on this info to their counselor so they feel a little more welcome on their first day!

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