Boys & Girls Club of Taunton CAMP RIVERSIDE. 388 Harvey Street, Taunton MA campriversidetaunton.

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1 CAMP RIVERSIDE 388 Harvey Street, Taunton MA campriversidetaunton.org Seasonal Only Boys & Girls Club of Taunton 31 Court Street, Taunton MA bgctaunton.org

2 DON T MISS OUT! Camp t-shirt included with enrollment Summer Day Camp for Youth Ages 4-13 Goldfish 4 Salamanders 5-6 Turtles 7-8 Hawks & Coyotes 9-13 Swimming & Swim Instruction Canoeing & Kayaking Fishing Archery Nature Hiking Basketball Soccer Gaga Ball Field Games Baseball Lacrosse Street Hockey Arts & Crafts Beach Volleyball Adventure Play Dance $160 per week/per child A Boys & Girls Club of Taunton membership is required. Extended Hours Available 7:30 am - 9:00 am and 4:00 pm - 5:30 pm AM or PM is $15 each or $30 per week/per child Financial Aid Available PACE Vouchers Accepted Registration Information 2018 Camp Weeks Monday - Friday 9:00 am - 4:00 pm A: June 25 - June 29 B: July 2* - July 6 C: July 9 - July 13 D: July 16 - July 20 E: July 23 - July 27 F: July 30 - August 3 G: August 6 - August 10 H: August 13 - August 17 I: August 20 - August 24 Available at the Club location 31 Court Street Taunton, MA or online at campriversidetaunton.org Child s immunization record, birth certificate, all completed camp forms and weekly deposits for each session are required at time of registration. Open Houses & Registration May 19 th June 9 th June 16 th 10 am - 12 pm

3 Required Forms Please provide the camp with any information that will help give your child a positive camp experience. Registration Form Every camper must have this form signed by a parent/guardian. Health History Every camper must have this form completed each year. Immunization Record Every camper must have this form or equivalent signed by physician. Payment Due Dates Payment is due one week prior to the camp session start date. Deposit Fee A deposit fee of $50 per week, per child is required at the time of registration. The deposit fee is not refundable and cannot be transferred to other programs, persons or sessions. This deposit is applied toward your total camp fee. Families with a current PACE voucher do not need to provide a deposit, but all paperwork including a copy of the voucher is required to reserve your child s place at camp. Early & Late Fee Policy There is a $10 fee for each 15 minutes that your child is left at the camp before or after the hours of operation. Children will not be allowed to participate in any Boys & Girls Club programs until the fee has been paid. This includes all activities and sports. Financial Assistance If economic or other family circumstances prevent your child from participating in our camp, please fill out a financial assistance application and return it to the camp no later than June 1, All requests are confidential. All required documentation must accompany request. Boys & Girls Club of Taunton welcomes all recipients of state vouchers and subsidy programs. Due to the number of campers who receive financial assistance we are only able to provide each child with up to two weeks of camp under this assistance program. PACE Vouchers If you are eligible to receive funding through PACE Child Care Works, a copy of the voucher is required to reserve a space for your child. If you have an approved voucher for camp you will be charged according to your parent fee amount. Cancellations, Refunds and Withdrawals A written two week notice is required to withdraw your child from camp. Tuition, less the $50 deposit, will be refunded if notice is received two weeks prior to your child s camp session. Refunds after the start of the camp session are made only if the child has an illness or an injury requiring doctor s care or a note from the physician stating that he/she is unable to participate in camp activities. Please be advised that refunds take 2-3 weeks. Requests for session changes should be submitted at least one week prior to the earliest session involved in the change. Authorized Pick Up Please list anyone who is 16 or older that you would allow your child to be released to when it is time to pick them up from camp. Proper identification is required before a child will be released. This policy is strictly enforced.

4 The Boys & Girls Club of Taunton complies with the Regulations of the Massachusetts Department of Public Health and is licensed by the Taunton Board of Health. Information on 105 CMR can be obtained by calling The Boys & Girls Club of Taunton takes the prevention of child abuse very seriously. Our Club is committed to taking proactive steps to protect children in all Boys & Girls Club programs and facilitiies. For a full copy of our child protection policy, visit our website at campriversidetaunton.org.

5 REGISTRATION FORM 2018 CAMP RIVERSIDE LAST FIRST MALE FEMALE DATE OF BIRTH AGE AT CAMP ENTERING GRADE MAILING ADDRESS CITY STATE ZIP CODE ADDRESS PARENT FULL EMPLOYER WORK PARENT FULL EMPLOYER WORK GUARDIAN IF DIFFERENT THAN PARENT EMPLOYER WORK DO BOTH PARENTS LIVE AT? YES NO MOTHER S DATE OF BIRTH FATHER S DATE OF BIRTH EMERGENCY CONTACT OTHER THAN PARENT RELATION AUTHORIZED PICK UP RELATION AUTHORIZED PICK UP RELATION DO NOT RELEASE MY CHILD TO THE FOLLOWING PERSON(S) GROUP WITH FRIEND(S) HOW DID YOU HEAR ABOUT CAMP? FRIEND/FAMILY BILLBOARD WEBSITE SOCIAL MEDIA FACEBOOK LIVE IN AREA BROCHURE FROM SCHOOL RETURN CAMPER OPEN HOUSE OTHER, please specify Camp Weeks Place an X next to your desired camp selections & where extended care is needed CAMP $160/WEEK CAMP $128/July 4 th Week Payment Information Full Payment Enclosed Deposit only Current Member Non-member Check Total $ Cash Total $ Credit Card Total $ Credit Card Number Name as it appears on Credit Card Signature Please circle t-shirt size: Youth S Youth M Youth L Adult S Adult M Adult L Adult XL Parent Agreement EXTENDED CARE: AM OR PM: $15/WEEK EACH BOTH AM & PM: $30/WEEK CAMP AM PM BOTH CAMP AM PM BOTH CAMP AM PM BOTH A: June 25 - June 29 B: July 2 - July 6 C: July 9 - July 13 D: July 16 - July 20 E: July 23 - July 27 F: July 30 - August 3 G: August 6 - August 10 H: August 13 - August 17 I: August 20 - August 24 NO FEE Expiration Date Date Must complete membership application $35 MEMBERSHIP FEE Payment is due one week prior to the camp session start. Non-member add $35 $ Total All Sessions $ Extended Care Fees $ Total Fees Due $ I have read and understand the payment and refund policies for the Boys & Girls Club of Taunton Summer Day Camp Program. I give my child permission to participate in camp activities including, but not limited to adventure programs, swimming, basketball, soccer, archery, arts & crafts, travel field trips and walking field trips. In consideration of participation in activities and programs of the Boys & Girls Club of Taunton and to use its facilities, equipment, and machinery, in addition to any fee or charge, I do hereby waive, release, and forever discharge the Boys & Girls Club of Taunton and its officers, agents, employees, representatives, (collectively the BGCT ), from and all responsibilities or liability for injuries or damages to myself, including those caused by negligent act or omission of the Boys & Girls Club of Taunton, or in any way arising out of our connected with my participation in any activities at the Boys & Girls Club of Taunton or the use of any equipment at the Boys & Girls Club of Taunton. I agree to adhere to all policies set by the Boys & Girls Club of Taunton. I am aware that incomplete or unsigned registration forms will be returned to me for completion. I hereby give permission to the medical personnel selected by the director to act in the best interest of my child in the event of an emergency. Every effort will be made to contact the parent, guardian and emergency contacts. I give permission for the Boys & Girls Club of Taunton to take photographs for use in BGCT promotional materials while I/we participate at Boys & Girls Club of Taunton facilities. I do not wish photos to be taken of my child Signature of Parent or Guardian Required Date OFFICE USE ONLY DATE PROCESSED: PROCESSED BY:

6 CAMP HEALTH HISTORY FORM Form must be completed annually This completed form may be photocopied for trips out of camp LAST FIRST MALE FEMALE DATE OF BIRTH AGE AT CAMP ENTERING GRADE PARENT OR GUARDIAN EMERGENCY CONTACT OTHER THAN PARENT OPERATIONS OR SERIOUS INJURIES INCLUDE DATES CHRONIC OR RECURRING ILLNESS OR MEDICAL CONDITION DIABETES YES NO DIETARY RESTRICTIONS ACTIVITY RESTRICTIONS GUARDIAN IF DIFFERENT THAN PARENT ALLERGIES PLEASE BE SPECIFIC AS TO SEVERITY OF ALLERGY FAMILY PHYSICIAN CURRENT MEDICATIONS OFFICE REASON FOR MEDICATION AUTHORIZATION TO ADMINISTER MEDICATION TO A CAMPER NEEDING TO TAKE MEDICATION AT CAMP To be completed by Parent or Guardian OF LICENSED PRESCRIBER OF MEDICATION ROUTE OF ADMINISTRATION DURATION OF ORDER SPECIFIC INSTRUCTIONS SPECIFIC PRECAUTIONS LOCATION WHERE MEDICATION ADMINISTRATION WILL OCCUR DOSAGE DATE ORDERED QUANTITY PROVIDED SPECIAL STORAGE REQUIREMENTS POSSIBLE SIDE EFFECTS ADVERSE REACTIONS OTHER MEDICATIONS TIME FREQUENCY MEDICATION EXPIRATION DATE I HEREBY AUTHORIZE CAMP NURSE OR DESIGNATED INDIVIDUAL TO ADMINISTER TO MY CHILD THE MEDICATIONS LISTED ABOVE IN ACCORDANCE WITH 105 CMR CHILD S HEALTH HISTORY & DIAGNOSIS Please check those that apply SIGNATURE OF PARENT/GUARDIAN FREQUENT EAR INFECTIONS MONONUCLEOSIS ASTHMA HEART DEFECT CHICKEN POX ADD CONVULSIONS/SEIZURES MUMPS ADHD DIABETES MEASLES OCD BLEEDING OR CLOTTING DISORDER GERMAN MEASLES ODD SPECIAL CONDITIONS Please list any conditions or physical limitations that the camp staff supervising your child should be made aware of in order for your child to have a positive camp experience. Example: Fear of water, lightning, etc. HYPERTENSION AUTISM SPECTRUM DISORDER including Aspergers OTHER Please specify This health history is correct as far as I know and the person herein described has permission to engage in all prescribed camp activities, except as noted. Authorization for Treatment: I hereby give permission to the medical personnel selected by the camp director to act in the best interest of my child in the case of an emergency. Every effort will be made to contact a responsible adult. SIGNATURE OF PARENT/GUARDIAN OR ADULT CAMPER/STAFF RELATIONSHIP TO CHILD DATE THIS FORM MUST BE SIGNED BY A PARENT/GUARDIAN FOR ANY CAMP OR STAFF MEMBER UNDER 18