2018 RA Camp Discount Application

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1 2018 RA Camp Discount Application Thank you for choosing Reston Association and placing your child(ren) in our care. The intent of the RA Camp Scholarship Program is to provide financial assistance to families that might not otherwise be able to afford the full cost of high quality child care. Below is a checklist and outline of required items to help guide you to complete the application process. We will not approve any camp requests unless all details of the application are submitted. 1. Maximum of 2 sessions per camper can be approved with your application. Your fee would be $25 per session. Transportation or Extended Care and one camp shirt are included in the approval. 2. Once approved for a camp session any transferring of camps will be charged a $20 fee per transfer. Guidelines and Policies 3. Applicant/Guardian must be a Reston Association member and provide proof of owning or renting a RA property 4. Proper forms listed below must be submitted for approval of camp discount 5. All applicants are contacted on a first come first serve basis provided all the necessary forms and documents are submitted. 6. Payment must be paid when we contact you to enroll for the camp. 7. There are no refunds for the payment of the discounted camp fee. 1. Fill out application forms (see below) and return to Sr. Program Manager at Sunrise Valley Dr. Reston, VA Please contact by phone at to make appt. to submit forms. 2. Complete the section on the back of this form to select the two camps you wish to choose. Please select your top two choices per session. Application Steps 3. All forms will be collected on a first come first serve basis. 4. Applicants will be called starting April 1 st by the Camp Registrar for approved applicants for camp selections. If you do not have the forms completed or up to date documents, you will be contacted for the missing forms and not approved until correct forms are submitted. 5. You will have 72 hours to reply to us to enroll your child. If we do not hear from you, we will move to the next person in the system for the camp discount. Required Forms Program Fee Discount Application Form Provides documentation of participation in any of the following; a) Supplemental Nutrition Assistance Program (SNAP) letter from SNAP, not just the card. b) Women, Infants, Children (WIC) letter from WIC, not just the card. c) Current Eligibility Notification letter from Fairfax County Public Schools for Free/Reduced lunch d) Income assistance program as defined by a social services agency* (Federal, State, FISH, Cornerstones) Camp Registration Form complete all blanks on this form. If there is a blank that is not applicable, please write N/A. IDENTITY / AGE Verification Form School Entrance Health Form

2 2018 Parks & Recreation Department Program Fee Discount Application Reston Association will waive or discount the fee for certain programs considering the following criteria: Group swim lessons: maximum 2 sessions per student Tennis lessons: maximum 1 session per season Camp: The applicant/student maximum is a member 2 sessions of the per Reston camper Association - $25 program fee required for each camper Applicant/guardian is a Reston Association Member and provide proof of owning or renting a RA property. Minors must be registered by a legal parent or guardian; The applicant/student provides documentation of participation in any of the following; o Current Eligibility Notification letter from Fairfax County Public Schools for free/reduced lunch o Supplemental Nutrition Assistance Program (SNAP) o Women, Infants, Children (WIC) o Income assistance program as defined by a social services agency* (Federal, State, FISH, Cornerstones) *Authorized representative of any social services agency must complete the shaded box at the bottom of this form. Fee waived programs are subject to a first come, first serve basis pending funds are available. Applicant Information: Parent/Guardian Name (If applicant/student is a minor): Date: Address: Reston, Virginia, 201 Primary Phone: Secondary Phone: address: Verification by Member Services or Program Staff: Agency or organization used for verification: Name of program used for verification: RA Staff Printed Name & Signature: I am an authorized representative of a social service organization verifying that the applicant/student meets the criteria established above and would not be able to participate in recreational programs without a discounted fee. Printed Name: Name of organization: Signature: Direct phone: Address: Virginia, 201 Main phone number: Date: Return this form to applicant/student Customer is to present this form at registration. This application must be renewed on an annual basis. For questions please contact Member Services at or

3 , Camper s Last Name, First Choose a Camp (Circle up to 2 session(s) you want to attend) (Session # is listed w/ corresponding camp) SESSION Camp / Age(s) June June (no 7/4) Aug. 3 Aug Aug Jr. Day Camp (5-7) Camp on Wheels (5-13) 4B Day Camp (7-11) Sportsters (6-9) Science Camp (8-12) Wilderness Camp (11-14) 3B 4A Junior Lifeguard (11-14) 2B 4B Counselor in Training (14-16) TRANSPORTATION SESSION EXTENDED CARE AM PM 1 AM PM AM PM 2 AM PM AM PM 3 AM PM AM PM 4 AM PM AM Pick up Location: PM Drop Off Location: Included in the Discounted Program Fee. May choose one if needed of either Transportation or extended care. Camp T-Shirts One shirt is included with Program Fee Discount acceptance per camper. Please circle desired size below. Additional shirts can be purchased at Member Services for price listed below. Youth / $8.00 per Small (4-6) Medium (8-10) Large (10-12) Adult / $10.00 per Small Medium Large Extra Large

4 2018 Camp Registration Form Part I Participant Information (use one form per camper) Child s Name (Last, First, Middle) Nickname Birth Date (Month/Day/Year) Sex School Attend Grade Level completed Check if registered in 2016 RA Camps Part II Parent / Guardian Information (number of priority 1-3 which phone number to contact) Parent/Guardian #1 Name (Last, First) Nickname Employer Info. (Company Name) Home Phone Priority Cell Phone Priority Work Phone Priority o o Not Applicable Same as above Parent / Guardian #2 Name (Last, First) Nickname Employer Info. (Company Name) Home Phone Priority Cell Phone Priority Work Phone Priority Part III Emergency Contact / Pick Up Authorization (number of priority 1-3 which phone number to contact) (VA licensing requires 2 contacts w/ phone and address beside parent/guardian.) Emergency Contact #1 Last, First) Relationship to Child Home Phone Priority Cell Phone Priority Work Phone Priority Emergency Contact #2 (Last, First) Relationship to Child Home Phone Priority Cell Phone Priority Work Phone Priority Other Person(s) Authorized to Pick Up your child (if any): *Photo ID is required upon pick up of camper Person(s) NOT Authorized to Pick Up your child (if any). Appropriate paperwork such as custody papers must be attached if a parent is NOT allowed to pick up the child PLEASE CONTINUE BACK

5 Part IV Child s Physician Child s Physician / Insurance Information Physician Phone Number Insurance Company Name Policy Holder s Name Policy Number Part V Child s Medical Information (if nothing, please note as N/A) PLEASE NOTE ANY ALLERGIES, INTOLERANCES TO MEDICATION, FOOD OR OTHER SUBSTANCES Medicine: Food: Other: PLEASE LIST ANY SPECIAL NEEDS AND MEDICATION CHILD IS PRESCRIBED Special Needs: Developmental Delays: Medication: Chronic Physical Problems / Special Accommodations (please attach additional pages if needed): Check here if your child will be required to take medication during the camp day. Must complete VA Medications Forms Part VI Parent Statement of Authorization & Understanding (initial required for consent) I grant permission for Reston Association to photograph and video my child and to use such photographs and video for RA promotional and advertising purposes and for trade purposes. I understand that I am to leave my child at the RA program site only if there is a staff member present to receive and supervise my child. In the event that my child becomes ill during camp, I understand that I will be contacted as soon as possible. If I am not able to be reached, my child s emergency contact will be notified. It is my responsibility to arrange for the child to be picked up from the camp as soon as possible. I grant permission for my child to participate in swimming activities, following a standard swim test performed by RA staff. (Not applicable to Nature Tots Camp or Camp on Wheels) I authorize the application of sunscreen and insect repellent to his or her child by RA staff. (Non-prescription OTC Skin Products Authorization Form required available at I will submit a physical exam from VA School entrance health form or another physical performed by a U.S. licensed physician. (VA school entrance Health form is available at I will submit a VA Dept. of Health or physician s immunization form that documents the immunizations required by VA State Board of Health. I agree to inform the camp staff of any illnesses including communicable diseases that my child may contract. I have received a copy of the RA Camps Parent Handbook on our website at (hard copy is available on request)

6 Part VII Permission & Release Agreement By executing this Permission and Release Form, I hereby: certify that I have read, understand, and agree to all of the terms and condition of this entire document and hereby grant permission for my Minor Child, named above, to participate in Reston Association Camps and any activities and field trips, such as those listed below, for all sessions which s/he attends, except as otherwise expressly noted by me or by my Minor Child s physician in writing and provided to the Reston Association (see Health Form as applicable): and Acknowledge and give my permission for my Minor Child to be taken and transported to and to participate in certain camp activities, both on-site and off-site, where personal injury can occur. Accordingly, in the case of an emergency, I hereby authorize any emergency health care responders and/or the doctor or the hospital to which my child or children may be brought (and whomever they may designate or their assistants) to perform any emergency procedures or operations, to give treatment to administer anesthetics or medication to my child deemed by the healthcare provider to be reasonable and necessary under the circumstances. release Reston Association, its officers, directors, employees, representatives (including volunteers), and agents from all and any claims, causes of action, liability or other responsibility for any bodily injury, death, or property damage arising out of or related in any way to my Minor Child s participation in Camp Activities, except for injuries caused directly by the gross negligence or intentional misconduct of Reston Association. I further acknowledge and understand that I am fully responsible, including financially, for any and all incidents and claims related to or involving my Minor Child, and for the care of and care given my Minor Child; and represent and acknowledge that my Minor Child is covered by health insurance and that such health insurance coverage shall be the primary source of health insurance coverage in the event of any injury to my Minor Child; and agree to and do hereby indemnify, reimburse and hold the Reston Association its officers, directors, employees, representatives (including volunteers), and agents harmless from and against any claims and related costs, whether direct or indirect, including any attorney s fees and claims arising our of or related to my Minor Child s participation in Camp Activities., including any claims which might be brought by my Minor Child after attaining majority; and assume full risk and responsibility for my Minor Child s participation in any and all Camp Activities; and acknowledge that I have sole custody of Minor Child and authority to execute this Permission and Release Form exclusively on behalf of Minor Child, or, acknowledge that I have joint or shared custody of my Minor Child by the execution of this Permission and Release Form below by all parties having joint or shared custody of Minor Child. HIPAA Authorization Form I, (parent or guardian name) of (camper name), authorize any physician, nurse or health care provider, to communicate with the Reston Association staff, including the Reston Association Camp Director and/or his/her designee about my child s medical condition treatment and/or prognosis. I, further, authorize the Reston Association staff to disclose and/or discuss any known medical conditions of my child or information that they have with any physician, nurse or health care provider providing care to my child, including any information provided by me in this 2018 Camp Registration Form. These HIPAA authorizations are limited to through. [Dates of Applicable Camp] Parent/Guardian (Print) Parent/Guardian (Signature) Date

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