T O T H E D A Y C A M P CAMPER REGISTRATION FORM INSTRUCTIONS Thank you for choosing the Flock to the Kroc Day Camp for this summer. Our payment process will be completed online this year. Please follow the instructions carefully and if you need help or have any questions, contact the KFRC staff at 215 558 1500. The fee for 2018 Flock to the Kroc Day Camp will be $150.00 per week for members and $165.00 per week for non-members. Camp fee includes a camp program, t-shirt, trips, lunch (except trip days), swimming at the Kroc indoor waterpark, activities and more. A $25.00 non-refundable deposit is required for each week your child will attend camp. This deposit will hold your child s spot for the week until the full amount is due. The full amount is due by 4:00 PM on the Thursday before your child attends camp. If payment not received, the space may be forfeited to a child on the waiting list. Our group age policy states that your child may move up to the higher age bracket if their birthday occurs before September 1st. In addition to payment, registration forms need to be completely filled out, printed, signed and returned to the KFRC no later than three weeks before your child attends camp. This icon denotes a field that needs a signature in pen!
CAMPER INFORMATION ONE COMPLETE FORM PER CAMPER PREFERRED (nickname) BIRTH- AGE AT CAMP HOME ADDRESS CITY ZIP GENDER MALE FEMALE PARENT/GUARDIAN CELL BUSINESS EMAIL PARENT/GUARDIAN CELL BUSINESS EMAIL T-SHIRT SIZE YOUTH: SMALL MEDIUM LARGE X-LARGE ADULT: SMALL MEDIUM LARGE X-LARGE XX-LARGE EMERGENCY CONTACT #1 (OTHER than parent/guardian): EMERGENCY CONTACT #2 (OTHER than parent/guardian): We require at least three emergency contacts/adults authorized for pick-up other than the parents listed on the Camper Registration Form. PEOPLE AUTHORIZED TO PICK-UP MY CAMPER: RELATIONSHIP RELATIONSHIP RELATIONSHIP PEOPLE NOT AUTHORIZED TO PICK-UP MY CAMPER:
HEALTH HISTORY & EMERGENCY CONTACT INFO CHILD S PARENT S OF BIRTH HEALTH INSURANCE YES NO COMPANY POLICY # FAMILY DOCTOR DOCTOR S ADDRESS HEALTH HISTORY The information provided will assist our staff in providing the best care for your child. Check if applicable or allergic: DIABETES ASTHMA CARRIES EPI-PEN EPILEPSY CARRIES INHALER BEHAVIORAL CHALLENGES INSECT STINGS PENICILLIN If you selected one of the above, please briefly explain below: ARE YOUR CHILD S IMMUNIZATIONS UP TO? YES NO OF LAST PHYSICAL HAS YOUR CHILD RECENTLY HAD ANY INFECTIOUS DISEASES? NO YES OF LAST TETANUS SHOT If exempt, please submit copy of your immunization Exemption Waiver (please list which one) DIETARY RESTRICTIONS RESTRICTIONS ON PHYSICAL ACTIVITY OF ANY MEDICATION(S) PURPOSE OF MEDICATION(S) MY CHILD IS WATER SAFE Due to safety considerations, the only flotation devices permitted are 1-piece swimsuits with flotation sewn into the suit by the manufacturer PLEASE PROVIDE ANY FURTHER INFORMATION THAT YOU MAY DEEM VALUABLE REGARDING YOUR CHILD S HEALTH EMERGENCY CONTACT #1 (OTHER than parent/guardian): EMERGENCY CONTACT #2 (OTHER than parent/guardian): PERMISSION TO PROVIDE NECESSARY TREATMENT OR EMERGENCY CARE: I hereby grant permission for immediate emergency medical treatment by professional medical personnel (hospital, ambulance, etc.) in the event I cannot be reached. This permission is granted for emergency care both on the Kroc Campus (4200 Wissahickon Avenue, Philadelphia, PA 19129) and while on Day Camp trips. SIGNATURE OF PARENT/GUARDIAN
PARENT/GUARDIAN RELEASE FORM I hereby grant to The Salvation Army and those acting under its authority, to record on film, tape or otherwise my name, likeness, voice, performance and actions. I acknowledge my performance may be edited as desired by The Salvation Army and may be used in perpetuity and authorize others to use, such recording as The Salvation Army sees fit throughout the U.S., Canada and abroad on television & radio broadcasts and rebroadcasts, in theatrical and non-theatrical exhibition, audio-visual/school/home use, in any production, in any and all media now known or hereafter devised throughout the world, and to use, license, market, and distribute in any medium or forum said productions and any other productions in which said recording may be incorporated. I waive the right to inspect or approve any such use of my name, likeness, voice or actions, and hereby also authorize The Salvation Army and those acting under its authority to use my name, likeness, voice, or actions, biography, and/or composition for purposes of promotion and publicity in connection with the program materials. Further, I hereby waive and forego any compensation for my appearance in the production. I release The Salvation Army, their officers, agents, employees, and those acting under their authority from all claims and liabilities of any kind arising out of or in connection with the making of or uses of such films or recordings. The rights granted herein shall insure to the benefit of The Salvation Army, its licensees, successors and assigns. I hereby grant permission for my child to participate in the total camp program. I hereby grant permission for my child to be transported by contracted bus companies and campdesignated vehicles for medical emergencies, trips, and etc. I have read and understand all content and materials within the 2018 Flock to the Kroc Parent Handbook. I hereby certify the above information is true and correct. By signature, I am requesting my child be enrolled at The Salvation Army Ray & Joan Kroc Corps Community Center Day Camp program. PARENT/GUARDIAN SIGNATURE WITNESS SIGNATURE
CAMPER CONDUCT BEHAVIOR CONTRACT PARENTS, GUARDIANS PLEASE READ THIS DOCUMENT WITH YOUR CAMPER(S) All Kroc Campers should strive to be caring, honest, respectful, and responsible. When inappropriate behavior occurs, every effort is made by the Kroc Staff to re-direct camper behavior and to help find ways to resolve behavior issues; however, some behavior is not acceptable at camp and, if not corrected, will lead to dismissal from camp. Such behavior includes, but is not limited to: a. Disrespect b. Improper anger management c. Destruction of property d. Theft e. Fighting with fists or words f. Bringing a weapon to camp g. General disregard for FLOCK TO THE KROC DAY CAMP rules h. General disregard for instructions given by FLOCK TO THE KROC staff members i. Behavior that does not align with the Mission of The Salvation Army As a Kroc Camper, I will to the best of my ability, obey all Kroc Camp rules that are designed to ensure a safe, wholesome summer for everyone! I understand, if I have a problem, I will talk to a Kroc Camp Staff member immediately. PARENT/GUARDIAN SIGNATURE KROC CAMPER SIGNATURE
FINANCIAL AGREEMENT PAYMENT INFO & SCHEDULE OF CHILD OF PARENT/GUARDIAN REGISTRATION FEE: (Money Order, payable to The Salvation Army) $25.00 NON-REFUNDABLE DEPOSIT TO HOLD WEEKLY SPOT $150.00 MEMBER FEE $165.00 NON-MEMBER FEE Full amount due by Thursday before the week the camper will be attending (for reference, see schedule below). ATTENDING WEEK PAYMENT DUE 6/18-6/22 6/19 6/25-6/29 6/21 7/2-7/6 6/28 7/9-7/13 7/5 7/16-7/20 7/12 7/23-7/27 7/19 I understand the fee for Flock to the Kroc Day Camp is due no later than 4:00pm on the Thursday before the week the child will attend camp. I understand that if the weekly fee is not paid in full by this date, I will forfeit my camper s reserved spot I further understand the weekly fee is non-refundable. PARENT/GUARDIAN SIGNATURE