First Baptist Church Broad - BROAD NEXT SUMMER CAMP APPLICATION

EMERGENCY INFORMATION FORM

First Name

Last Name

Birthdate

Gender

Grade

Parent First Name

Parent Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Secondary Parent First Name

Secondary Parent Last Name

Address

Phone Number

HEALTH INFORMATON

PLEASE LIST THE LAST DATE FOR THE FOLLOWING SHOTS

POLIO

Date Input

TETANUS

Date Input

MEASLES

Date Input

DPT SERIES

Date Input

Exception: If a child or staff member has a statement from a physician or medical professional for medical or religious reasons

Allergies

PHYSICAL OR DIETARY RESTRICTIONS

Text Input

*Does Your child have or have they ever had an I.E. P/504?

Yes

No

IF YES EXPLAIN WHY

NAME OF FAMILY PHYSICIAN

First Name

Last Name

Phone Number

After Hours Phone Number

Hospital Preference

INSURANCE INFORMATION

Name of Medical/Hospital Insurance Carrier

Address

Insurance Phone Number

Policy Number

Group Number

My Child Does Not Have Health Insurance

Emergency Authorization: In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the First Baptist Church-Broad adult in charge to secure proper treatment until family is present to assume responsibility of decision making for the child named above. I give my permission for this form to be photocopied and kept on file for on and off site events.

AUTHORIZATION PICK-UP FORM

CHILD NAME

First Name

Last Name

PARENT NAME

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Secondary Phone Number

EMERGENCY CONTACTS

First Name

Last Name

Phone Number

RELATIONSHIP

First Name

Last Name

Phone Number

RELATIONSHIP

First Name

Last Name

Phone Number

RELATIONSHIP

WHO IS AUTHORIZED TO PICK UP YOUR CHILD/ CHILDREN?

First Name

Last Name

RELATIONSHIP

First Name

Last Name

RELATIONSHIP

First Name

Last Name

RELATIONSHIP

(Photo Identification is required to pick up ALL children. Anyone that is NOT listed on this authorization sheet will not be able to pick up your child. If you plan to have someone not listed on this form pick up your child, please make arrangements with Hi-DEF Staff and update your form.

Signature

FINANCIAL AGREEMENT

CHILD INFORMATION

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

COST:
*Registration & Activities Fee: $150 (one time; non-refundable)
*Weekly Tuition: $90
*Tuition must be paid weekly (Monday)
*REGISTRATION FEE MUST BE PAID PRIOR TO ENROLLMENT

PLEASE NOTE:
- Registration fees are only prorated if your child begins after the first week.
- There are NO tuition adjustments for sick days or vacation time.
Returned Checks:
*A fee of $35.00 will be charged for returned checks
*Post-dated checks will NOT be accepted.

Voluntary Withdrawal:
*At any point a parent may withdraw a child from camp. Refunds will NOT be given.
Involuntary Withdrawal/Agency:
*Non-Payment of tuition
*Failure to follow policies and camp rules
*Lack of Parent cooperation to address specific concerns
I have read and I agree to the terms and conditions as stated in this application/agreement. I have read, understand and agree to abide by the financial policies as outlined above.

Signature

SIGN IN/OUT INFORMATION:
Signing in camper(s)
*A parent/authorized person MUST sign in children.
.
Signing out camper(s)
*Photo Identification may be randomly requested.
*ALL Children must be signed out daily.
*Anyone that is NOT listed on the authorization sheet will not be able to pick up your child.
*If you plan to have someone not listed on the authorization form to pick up your child, please make arrangements with Hi-DEF Staff PRIOR to pick up. Failure to follow this policy can lead to involuntary withdrawal.

ATTIRE:
*Active Sports Wear & Closed Toe Shoes
* Camp T-shirt MUST be worn for field-trips

MEALS:
Breakfast and afternoon snacks will be provided daily. Parents are to provide lunch and a reusable water bottle.

MEDICAL INFORMATION:
Hi-DEF staff does NOT administer medication. Parents are advised to give children medication before or upon arrival to camp if needed. However, if administered upon arrival, parents are required to wait at least 20 minutes before leaving in the event of reaction. Make sure ALL Health information is CURRENT. If an emergency occurs, we will use the information provided on the application.

MEDICAL EMERGENCY PROCEDURE:
If your child is injured and requires more than basic first aid, the following steps will be taken:
*Staff will notify parent/guardian and depending on severity of injury, 911 will be called.
*If parent/guardian is not available, the emergency contact listed on the registration form will be contacted.
*If no one on the registration form can be contacted and it is imperative that the child be immediately transported for medical care, Hi-DEF staff will accompany the child in the transport.
*Paramedics will transport the child to the nearest hospital. Onsite staff will continue to make efforts to contact parents/guardian/family and remain in contact with staff in transport for updates.
**FIELD TRIPS: Parents will receive timely notification of any scheduled field trip(s) outside of the building and are encouraged to attend whenever possible. Parental consent forms MUST be completed for EACH field trip.

Adapted from the guidelines of the CDC with the American Campus Association (10/21).

High vaccination coverage is needed for all persons attending/ participating in the camp. Prevention strategies are important guiding principles for school-age and youth-based camps. Covid-19 protocol will be implemented to combat secondary spread between staff members, campers, and their families.
Protocols are as follows:
- Masking is optional
- Temperature checks will be done randomly
- Hand hygiene throughout the day
- Sanitizing classrooms throughout the day
- Isolation room sanitized and stocked with required supplies to monitor campers and staff until signed out
These strategies are critical for prevention of COVID-19 outbreaks in congregate settings and youth camps.

ILLNESS:
For the health and wellness of ALL children and staff members, we ask that parents do not bring sick children to camp! If your child becomes ill during camp he/she will be brought to the isolation room, a parent or guardian will be notified, and asked to pick up the child ASAP.

DISCIPLINE:
Should a disciplinary problem arise, staff will respond immediately to the situation. Discipline steps are progressive and include the following:
1. A verbal warning/redirection
2. “Reflection Time” with support in the classroom
3. Removal from classroom for reflection with support and reset
4. Parent Call and write up/ behavior modification needs
5. Parent Conference with plan of action (POA)
6. Suspension
7. Expulsion

Suspension is definite when a child presents unacceptable behavior that causes continued disruption in a classroom setting or camp activities on or off site. For the safety of all children and staff members, the following behaviors will NOT be tolerated and disciplinary action will be taken immediately:
*Foul and sexually suggestive language/behavior
*Damage and/or theft to other’s property
*Bringing weapons and/or illegal items to camp
*If a child deliberately harms another child and / or staff person
The Staff will complete disciplinary forms. A copy of the form will be made available to the parent and the concerns will be discussed with the parent/guardian the same day. No refunds will be given if your child is removed from the camp for ongoing documented disciplinary reasons.
AGENCY WITHDRAWAL INFORMATION:
Campers will be withdrawn from camp for the following reasons:
*Non-Payment of tuition fee
*Failure to follow policies and camp rules
*Lack of parental cooperation to address specific documented concerns
PLEASE NOTE: ALL PARENTS ARE REQUIRED TO ATTEND MANDATORY ORIENTATION PRIOR TO CHILDREN STARTING CAMP (NO EXCEPTIONS!)

First Name

Last Name

Signature