Jefferson Summer Camp 2022 Mandatory Pre-Registration

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.

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

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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 2022)

Pre-K

Other (please specify)

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* Child's School (as of September 2022)

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

Northmore Nursery School

Ken-Ton UPK: Hamilton

Ken-Ton UPK: Holmes

Ken-Ton UPK: Franklin

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 XS

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XL

Adult XXL

Adult 2X

Adult 3X

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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

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* 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

Question Title

* 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

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* 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

IF your child has an allergy, please explain what allergy and what actions to be taken in event of an allergic reaction:

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* 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 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.

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 5-8

Week 2: July 11-15

Week 3: July 18-22

Week 4: July 25-29

Week 5: August 1-5

Week 6: August 8-12

Week 7: August 15-19

Comments (optional)

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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.

Monday

Tuesday

Wednesday

Thursday

Friday

Time to be released from camp:

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* Swimming at Lincoln Pool will be included as part of our weekly programming, and will be included in the camp fee. Weekly field trips will be offered 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 whether or not you would send your child on field trips/swimming trips.

Yes, I would like my child to go on field trips! I understand there will be an additional cost and registration step.

Yes, I would like my child to go swimming!

Maybe, depends on the destination and/or schedule

I do not want to pay extra for field trips

I do not want my child to go off-site (for other reasons)

Other (please specify)

Question Title

* 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 to summer camp at Jefferson?

Cost

Location

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

Hours

His/her friends attend

Reputation/recommendation

Other (please specify)

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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!