2008 Camper
Registration Form
Mail registration,
health form, and check to:
Parkminster Summer’s Best Two Weeks
(Make checks out to Parkminster SB2W – Returning spots will be held one week after registration is mailed)
Camper’s Name: Nickname
(if used):____________________
Home Phone: ( ) -________ Home Address: _________________________________
Male or Female (circle one) (state/zip code) _____________________________
Grade (September 2008):____________Present Age: ________Date of Birth:
______________
Height: ___________ Weight: ___________ T-Shirt Size: ___________
# of
previous years at Day camp (not munchkins): __________ Roman or Galatian
(circle one)
Parent or Guardians’
Name(s):_____________________________________________________
Is camper living with both parents?
Yes or No (circle one) If not,
with whom? ______________
Name of church you currently
attend: _______________________________________________
Briefly describe what you hope your child will get out of camp:
Emergency Contacts (please provide
at least three names)
Primary Parent/ Guardian’s Name:
__________________ Relationship to camper: ___________
Phone Number: ( )
-__________ Alternate number: ( )
-__________
Second Parent or Guardian’s Name:
_________________ Relationship to camper: ___________
Phone Number: ( )
-__________
Alternate number: ( ) -__________
Third Name:
______________________ Relationship to
camper: ___________
Phone Number: ( )
-__________ Alternate
number: ( ) -__________
May we contact this third person during the overnight if necessary? Yes or No (circle one)
Volunteer Opportunity (check box if interested)
□
Our family would like to host a travel team counselor,
and we would prefer a (male / female / either)
□
I am interested in being the
Health form INCLUDED. Application must be
accompanied by complete medical
release
form to reserve a spot for your
child.
(A doctor’s examination and signature
are not required on
this form except for the medication permission at the bottom.)
Camper Name: _____________________
Medical Insurance (carrier and policy #): ______________________ #____________________
Physician’s Name:__________________________ Physician’s Phone: ( )_____-_________
Immunizations (give date of most
recent vaccine, “up-to-date” not acceptable)
|
Tetanus |
Measles |
Polio |
|
Diphtheria |
Mumps |
Varicella (Chicken Pox) |
|
Pertussis |
Rubella |
Haemophilus (Hib) |
|
Hepatitis
B |
Other |
|
Operations, serious injuries or
illnesses and dates: _____________________________________
Penicillin or other drug reactions:
__________________________________________________
Allergies:
_____________________________________________________________________
Prescription medications:
_________________________________________________________
List existing medical conditions
(such as ADD, nosebleeds, car sickness, headaches, etc.):
_________________________________________________________________________
Describe any additional physical or
emotional needs: _________________________________
To be completed by parent/guardian:
I hereby grant permission for______________________(camper’s name) to participate in Summer’s Best Two Weeks
day camp and overnight trip.
______________________(camper’s name) may participate actively in the total program, except as follows:
____________________________________________________________________________________________________________________________________________________________
I
approve the application and conditions above.
I have written any necessary and pertinent information concerning our
family and our child. In case of
emergency, I understand that every effort will be made to contact me. If I cannot be reached, I hereby give
permission to the physician selected by the
Parent/Guardian
Signature: ____________________________________________________ Date:
_____________
Per
Medication to be administered at camp: ___________________________________________________________
Dose: ___________________________________
Time: ___________________________________
Physician's signature: __________________________________________ Date: __________________________
SUMMER’S
BEST TWO WEEKS 2008
·
PLACE: Parkminster Presbyterian Church,
· DATES:
· COST: $185 for
first sibling, $165 for all additional siblings at camp
(This includes:
· AGES: 7-13
years old: entering 2nd – 8th grades
·
TIME: Full Day
·
Refund Deadline:
·
Financial Aid: Applications
available upon request
· Activities:
Track and field, swimming, soccer, volleyball, kickball, an overnight, craft,
Bible study, basketball, and much more!
ü
All senior counselors are trained
and experienced.
ü If you
would like to volunteer some time in the camp office, please contact the camp
director.
For more information, please contact the camp director:
Liz
Irvine: (585) 820-8960
Church
Phone: (585) 247-2424
Email: SBTWParkminster@gmail.com
SBTW is under Monroe County Department
of Health permit.
Records of inspections can be
obtained in the camp office.
Rights and Responsibilities
The
regulatory program of the New York State Department of Health places specific
responsibilities on camp operators, and on local health departments that
enforce department regulations. Following is a summary of rights and
responsibilities:
Rights
of Parents and Guardians
·
To
be informed by the camp director, or his or her designee, of any incident
involving your child, including serious injury, illness or abuse.
·
To
review inspection and investigation reports for a camp, which are maintained by
the local health department issuing the camp permit to operate (present and
past reports are available).
·
To
review the required written camp plans. These are on file at both the camp and
the health department issuing the permit to operate.
Responsibilities
of the
·
To
inform you and the local health department if your child is involved in any
serious injury, illness or abuse incident.
·
To
screen the background and qualifications of all staff.
·
To
train staff about their duties.
·
To
provide supervision for all campers 24 hours a day at overnight camps, and
during hours of operation for day camps.
·
To
maintain all camp physical facilities in a safe and sanitary condition.
·
To
provide safe and wholesome meals.
·
To
have and follow required written plans for camp safety, health and fire safety.
·
To
notify the parent or guardian, with the enrollment application or enrollment
contract, that:
·
the
camp must have a permit to operate from the New York State Department of Health
or the designated permit-issuing official;
·
the
camp is required to be inspected twice yearly; and
·
the inspection reports and required plans are filed (address of state, county
or city health department) and available for their review.
Responsibilities
of Local Health Departments
·
To
review and approve the required written camp plans for compliance.
·
To
inspect camps to assure that: (1) all physical facilities are properly operated
and maintained; and (2) adequate supervision exists to provide a healthy and
safe environment in accordance with the New York State Sanitary Code.
·
To
issue a permit to operate when the required plans and inspection results are
satisfactory.
·
To
investigate reports of serious incidents of injury, illness and all allegations
of abuse or maltreatment.
·
When
requested, to provide parents or guardians of prospective campers an
opportunity to review inspection reports and required plans.
For further
information about health laws relating to summer camps, call the Monroe County
Department of Health at (585) 274-6065.