Summer Camp Registration

Summer 2019

 

CHILD'S INFORMATION
Child's Name
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Child's Preferred Name
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Date of Birth //
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Sex
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Grade Entering in Fall 2019
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Official School Email for Communication
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Phone Number to Call first -- ext
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Name of Person to Call First
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Relationship of Person to Call First to Child
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School Attended in 2018
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School Attending in Fall 2019
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Does the Child Have a Sibling Attending Camp?
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Name & Age of Sibling(s) at Camp with You
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If both parents have joint legal custody please type, both parents. If there is a custody agreement, please type who has primary legal custody. All custody documents must be given to the school office.
Person (s) or Agency Having Legal Custody of Child
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If both parents have joint legal custody please type, both parents. If there is a custody agreement, please type who has primary legal custody. All custody documents must be given to the school office.
Language
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PARENT / GUARDIAN CONTACT INFORMATION
Enrolling Parent
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Enrolling Parent's Relationship to Child
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Enrolling Parent's Home Address
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Enrolling Parent's Email Address
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Enrolling Parent's Home Phone --
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Enrolling Parent Employed By
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Enrolling Parent's Work Phone -- ext
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Enrolling Parent's Other Phone --
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Enrolling Parent's Marital Status
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Other Parent's Name
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Other Parent's Relationship to Child
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Other Parent's Home Address
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Other Parent's Email Address
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Other Parent's Home Phone --
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Other Parent's Place of Employment
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Other Parent's Work Phone -- ext
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Other Parent's Other Phone --
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Other Parent's Marital Status
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This is to be completed by the enrolling parent. The enrolling parent is the natural or adoptive parent or legal guardian with whom the student lives the preponderance of the school week and who enrolled the student in the school.
MEDICAL INFORMATION
Does your child have any Activity Limitations
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Does your child have a medical condition we should know about?
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Does he or she require daily medication?
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List any Allergies or Intolerance to food, medication, etc.
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Describe the action to be taken if an allergy, intolerance, etc. occurs
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EMERGENCY CONTACTS (NOT THE PARENTS)
One MUST live in Virginia
1st Emergency Contact
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One needs to be in Virginia.
Address
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Reminder one must be in Virginia.
Phone Number -- ext
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Relationship to Child
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2nd Emergency Contact
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Address
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Phone Number -- ext
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Relationship to Child
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SWIMMING AT WOODLEY POOL
St. Philip Camp includes swimming at Woodley Pool. We are lucky that the pool is within walking distance. Each child will receive a wrist band each day designating their swimming level, which they wear in the pool each day. Please mark which color is best for your child.
Swimming Level
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Swimming Procedures - Check ALL Boxes
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By checking the boxes you are agreeing to the following:
SUNSCREEN
Please check the option you would like to utilize. If you choose to provide your own sunscreen you will need to also provide a Virginia Medical Form.
Sunscreen Options
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WEEKLY REGISTRATION
Registration is done on a weekly basis. Please check all that you would like to enroll in, it is easier to cancel then to find teachers at the last minute. To avoid costly fees, please notify Mrs. Kathleen Warr via email at kwarr@stphilipecc.org one week prior to your payment due date.
Week 1: 6/10 - 6/14
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Week 2: 6/17 - 6/21
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Week 3: 6/24 - 6/28
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Week 4: 7/1 - 7/3 & 7/5 NO CAMP JULY 4TH
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Week 5: 7/8 - 7/12
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Week 6: 7/15 - 7/19
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Week 7: 7/22 - 7/26
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Week 8: 7/29 - 8/2
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Week 9: 8/5 - 8/9
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SMOOTHIE KING / PIZZA CHOICES
If you signed up for Smoothie King and/or pizza please fill out appropriate section
Smoothie King
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Pizza Slices
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AUTHORIZED PICK UP
This list should include parents (if applicable)
Authorized Pick Up: Who is authorized to pick up your child?
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Parents must be listed
Authorized Pick Up: Who is authorized to pick up your child?
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Parents Must be Listed
Authorized Pick Up: Who is authorized to pick up your child?
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Please list Emergency Contact
Authorized Pick Up: Who is authorized to pick up your child?
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Please List Emergency Contact.
Authorized Pick Up: Who is authorized to pick up your child?
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please list anyone else who might need to pick up your child
Authorized Pick Up: Who is authorized to pick up your child?
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please list anyone else who might need to pick up your child
Authorized Pick Up: Who is authorized to pick up your child?
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please list anyone else who might need to pick up your child
Person (s) NOT authorized to pick up my child from school.
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Appropriate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child.
POLICIES AND PROCEDURES
By checking each box you agree to the content contained.
Check ALL boxes below
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By checking each box you agree to the content contained.
Parent or Guardian Agreement I agree to notify the school within 24 hours if my child or any member of my immediate household has developed a communicable disease. I agree to notify the school immediately if the disease is life threatening. I agree to pick up my sick or injured child in a timely manner when contacted. If I cannot be reached, my emergency contacts can be called to pick up my child. Additionally, if I cannot be contacted in an emergency, the school has my permission to take my child to the emergency room of the nearest hospital and I hereby authorize its medical staff to provide treatment, which a physician deems necessary fro the well-being of my child.
Parent or Guardian Agreement
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SOCIAL MEDIA PERMISSION
Wavier information / Right to Object
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PAYMENT
$50 camp deposit
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Payment for each week of Camp
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ENROLLING PARENT SIGNATURE
Signature
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Please print your name below agreeing that all information submitted on this form is correct.
Date //
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Notice: All information requested on registration is required by the Department of Social Services under the 22 VAC 13-30-80. Code