2018 TCDN SUMMER CLUB CAMP REGISTRATION FORM

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1 2018 TCDN SUMMER CLUB CAMP REGISTRATION FORM Welcome to TCDN s 34th year of Summer Club! A fun filled camp for children entering grades 1-5, located on the grounds of the Swarthmore-Rutledge School. Summer Club offers weekly enrollment options for 10 weeks beginning the week of June 25th and ending on August 29th. Camp hours are 7:15am-3:30pm or 7:15am-6:00pm. All thematic segments include games and athletics, the arts, science and nature activities, along with community engagement, frequent water play, and field trips. Our Summer Club staff is experienced, enthusiastic and skilled. All staff members are First Aid and CPR certified. TCDN is an Equal Opportunity Care Provider. Thank you for choosing TCDN s Summer Club. Below you will find cost information and instructions on how to register your child for Summer Club. TCDN will provide care and 2 snacks per day. Parents must provide lunch daily (no glass containers or bottles please). A NON-REFUNDABLE deposit of $50 per camp week/ per camper is required with registration. Your child will not be registered until the deposit is received. If registration is after the payment deadline date, then full payment is due at the time of registration. Payment Due Dates: Weeks 1-5 payments are due no later than June 15th. Weeks 6-10 payments are due no later than July 20st. A late payment fee of $25 will be accessed on all accounts not paid by the required date. Payment & Fee Policy: Payments must be in the form or Cash or Checks only. Please make checks payable to TCDN. The $50 NON-REFUNDABLE deposit is applied toward the weekly cost. A 30 day written notice of withdraw is required for all refunds (minus the $50 per week deposit). No reduction in fees will be made for late arrivals, early departures, or days missed due to illness, vacation or any other reason. There is a fee of $2.50 per minute for late pick-ups after 3:30pm or 6:00pm. A $20 charge is assessed on all returned checks. Discounts: Early Bird: Register before 4/2/18 and receive a 5% reduction in your total tuition. Multiple Child: Families eligible for a multiple child discount will receive a discounted rate (please see rate information). Multiple children is defined as more than one child enrolled in the Summer Club. WSSD Elementary extended school year reading, math and ESL program participants will receive a reduced rate. Please call the administration office for rate details. Weekly Camp Tuition: Weeks 1,3-9 7:15am- 3:30pm $270 per week for the 1st child, $250 per week for the 2nd child 7:15am- 6:00pm $345 per week for the 1st child, $315 per week for the 2nd child Week 2 (no camp on July 4th) 7:15am-3:30pm $220 per week for the 1st child, $210 per week for the 2nd child 7:15am-6:00pm $280 per week for the 1st child, $260 per week for the 2nd child Week 10 (Monday-Wednesday Only) 7:15am-3:30pm $165 per week for the 1st child, $160 per week for the 2nd child 7:15am-6:00pm $215 per week for the 1st child, $205 per week for the 2nd child PAGE 1 of 5

2 Please complete all sections on this form. If there is a section that is not applicable, please write/ type N/A. Incomplete forms will not be accepted and we will be unable to provide care until all paperwork has been submitted. If you have any questions about completing this form, please contact the TCDN Administration Office at x221. PARTICIPANT INFORMTATION (Please type or print legibly) Child s Full Name Nickname School Grade Entering Age Date of Birth Other Schools / Programs Concurrently Attending Gender Primary address PARENT/GUARDIAN INFORMATION (Please designate which numbers to call first and please type or print legibly) Parent/Guardian Name Priority Priority Place of Employment Work Phone Priority Parent/Guardian Name Priority Priority Place of Employment Work Phone Priority Is there a custody agreement for the child? If so, please provide a copy EMERGENCY CONTACT INFORMATION (Two people to be called in the event that we cannot reach either parent/guardian) Emergency Contact Name Emergency Contact Name ALTERNATE PICK-UP PEOPLE (People who can pick up your child in addition to those mentioned above) Please type or print legibly Contact Name Contact Name PAGE 2 of 5

3 MEDICAL / DEVELOPMENTAL INFORMATION (Please complete all sections and please type or print legibly) Name, address and phone number of Child s Medical Provider Child s health insurance company and policy number: Does your child have any dietary restrictions? Does your child have asthma or any allergies and/or intolerances to food, medication or any other substances? What are the symptoms and action to be taken if any? (Please attach an action plan if available.) Does your child have any medical conditions or special needs the staff should know about? Does your child have an IEP or GIEP? Does your child have any behavioral or emotional issues the staff should know about? If yes, please explain: Is your child taking any medications to treat any of the above mentioned conditions? If yes, please explain: Comments/Notes to TCDN: PAGE 3 of 5

4 CHILD HEALTH REPORT (55 PA CODE , AND ) Required for children not currently enrolled in a TCDN school year program CHILD S NAME: (LAST) (FIRST) PARENT/GUARDIAN: DATE OF BIRTH: HOME PHONE: ADDRESS: CHILD CARE FACILITY NAME: FACILITY PHONE: COUNTY: WORK PHONE: I authorize the child care staff and my child s health professional to communicate directly if needed to clarify information on this form about my child. PARENT S SIGNATURE: DO NOT OMIT ANY INFORMATION This form may be updated by a health professional. Initial and date any new data. The child care facility needs a copy of the form. HEALTH HISTORY AND MEDICAL INFORMATION PERTINENT TO ROUTINE CHILD CARE AND DIAGNOSIS/TREATMENT IN EMERGENCY (DESCRIBE, IF ANY): DESCRIBE ALL MEDICATION AND ANY SPECIAL DIET THE CHILD RECEIVES AND THE REASON FOR MEDICATION AND SPECIAL DIET. ALL MEDICATIONS A CHILD RECEIVES SHOULD BE DOCUMENTED IN THE EVENT THE CHILD REQUIRES EMERGENCY MEDICAL CARE. ATTACH ADDITIONAL SHEETS IF NECESSARY. CHILD S ALLERGIES (DESCRIBE, IF ANY): LIST ANY HEALTH PROBLEMS OR SPECIAL NEEDS AND RECOMMENDED TREATMENT/SERVICES. ATTACH ADDITIONAL SHEETS IF NECESSARY TO DESCRIBE THE PLAN FOR CARE THAT SHOULD BE FOLLOWED FOR THE CHILD, INCLUDING INDICATION OF SPECIAL TRAINING REQUIRED FOR STAFF, EQUIPMENT AND PROVISION FOR EMERGENCIES. IN YOUR ASSESSMENT, IS THE CHILD ABLE TO PARTICIPATE IN CHILD CARE AND DOES THE CHILD APPEAR TO BE FREE FROM CONTAGIOUS OR COMMUNICABLE DISEASES? YES NO IF NO, PLEASE EXPLAIN YOUR ANSWER: HAS THE CHILD RECEIVED ALL AGE APPROPRIATE SCREENINGS LISTED IN THE ROUTINE PREVENTIVE HEALTH CARE SERVICES CURRENTLY RECOMMEND- ED BY THE AMERICAN ACADEMY OF PEDIATRICS? (SEE SCHEDULE AT YES NO NOTE BELOW IF THE RESULTS OF VISION, HEARING OR LEAD SCREENINGS WERE ABNORMAL. IF THE SCREENING WAS ABNORMAL, PROVIDE THE DATE THE SCREENING WAS COMPLETED AND INFORMATION ABOUT REFERRALS, IMPLICATIONS OR ACTIONS RECOMMENDED FOR THE CHILD CARE FACILITY. VISION (subjective until age 3) HEARING (subjective until age 4) LEAD RECORD DATES OF IMMUNIZATIONS BELOW OR ATTACH A PHOTOCOPY OF THE CHILD S IMMUNIZATION RECORD IMMUNIZATIONS DATE DATE DATE DATE DATE COMMENTS HEP-B ROTAVIRUS DTAP/DTP/TD HIB PNEUMOCOCCAL POLIO INFLUENZA MMR VARICELLA HEP-A MENINGOCOCCAL OTHER MEDICAL CARE PROVIDER: ADDRESS: SIGNATURE OF PHYSICIAN, CRNP OR PHYSICIAN S ASSIS- TANT TITLE: PHONE: LICENSE NUMBER: DATE FORM SIGNED: PAGE 4 of 5

5 STATEMENT OF AUTHORIZATION ( Signature Required below) 1. My child has permission to take walks or be transported by vehicle to participate in all TCDN Summer Club activities and related field trips. 2. In the case that your child becomes ill during the program, you will be contacted as soon as possible. If the parent or guardian is unable to be reached, the child s emergency contact will be notified. It is the responsibility of the parents or guardians to arrange for the child to be picked up from the center as soon as possible. 3. In the case that your child or anyone in the immediate household of the child develops a reportable communicable disease as defined by the State Board of Health, it is the responsibility of the parent to notify TCDN within 24 hours or the next business day in order for TCDN to take proper action, except in the case of life-threatening diseases which must be reported immediately. 4. My signature authorizes the management and staff of TCDN to act for me according to their best judgment in the event of a medical emergency and/or routine medical care. I/we grant permission for minor first aid, emergency medical treatment and/or routine medical care by the TCDN Summer Club staff, a rescue squad, or private physician and/or hospital or emergency health care facility staff, under the same circumstances as above, if needed. Any such action will be taken in the best interest of my child and will be reported to me/us as soon as possible. My signature waives and/or releases the TCDN of any and all liability and/or financial responsibility for any medical expenses incurred. 5. The parent/guardian authorizes the application of sunscreen (provided by the parent) for his or her child by TCDN staff. By Signing below, you are authorizing all of the above. Parent/Guardian Signature Date PHOTO RELEASE STATEMENT I hereby give permission to TCDN Summer Club to photograph and/or videotape my child for educational and/or promotional purposes. I understand the photos will be used to keep a journal of activities, and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of TCDN. SIGNATURE OF PARENT OR GUARDIAN DATE 2018 SUMMER CLUB ATTENDANCE Child s Name: Parent s Name: Please circle the weeks and time period of each camp session your child will attend. Theme Dates 7:15am-3:30pm Cost 7:15am-6:00pm Cost Week 1 6/25-6/29 $ $ Week 2 7/2-7/6 $ $ Week 3 7/9-7/13 $ $ Week 4 7/16-7/20 $ $ Week 5 7/23-7/27 $ $ Week 6 7/30-8/3 $ $ Week 7 8/6-8/10 $ $ Week 8 8/13-8/17 $ $ Week 9 8/20-8/24 $ $ Week 10 8/27-8/29 $ $ Please check if this child is eligible for a 2nd child discount. Please check if a child is participating in a WSSD summer extended school year program. *Extended school year program name and participation weeks: The below is for administrative purposes only: PAGE 5 of 5 Date Received by TCDN :

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