Read camp-henry-application-2011-12.pdf text version

DIana Rodriguez

212-254-3100, at. 228

Camper Information

Name: Street Address: City: Home Phone: L( Gender (Circle One): T Shirt Size (Circle One):

---L

Henry Street Settlement 2011 Summer Camp Application Camp Henry Day Camp

_ Date of Birth: _ _-----' _ _ State: Zip Code: Camper Cell Phone: L(

)L-

For Office Use Only

Date Received: Received By:

_

_

-,

_

Age: _ _

_

Apt Number:

-=Female Child: S

M

_

L

~

_

Male

Is your Child a Returning Camper (Circle One):

XL

Yes

M

No

L

XL

Adult: No

S

XXL

Do you wish to purchase extra 'i-shirts for your child at cost of $20 a piece: Current School: Grade: _

Yes Ethnicity:

If yes, how many:

_ _ _

What Languages are spoken in Camper's Home?

General Information

How did you find out about Camp Henry? Has Camper Previously Participated in a Henry Street Settlement Program? (Circle One): If Yes, WhatProgram(s)?: Can the Camper's Name, Address and Phone Number be placed in Our Camp Directory? (Circle One): Yes No Yes No _ _

Parent/Guardian Information

Primary Guardian #1

Name: Street Address: City: Home Phone: .... ( --'_ _ _ State: _ ( Cell Phone: .... _ _ Relationship to Participant: _ Zip Code: -'-_...,.._ _ Apt Number: _ _ _ _

Primary Language Spoken: 10blPosition:

Employer (if unemployed, write "None"): WorkPhone: .... ( ----'--

Parent/Guardian 2

Name: Street Address: City: Home Phone: .1.-(

---'

_

Relationship to Participant: _ Apt Number:

_ _ _

_

State:

_

-'-

Zip Code:

-=_ _

_

Cell Phone: L(

-=_

_

Primary Language Spoken: 10blPosition:

Employer (if unemployed, write "None"): Work Phone: L(

-.L

-=Yes No

_

Is the Above Person Authorized to Pick-Up My Child at the End of Each Day or in the Event of an Emergency:

Emergency Contact Information

The first attempt will be made to contact the camper's parents/guardians. Emergency Contacts listed below must be a maximum of 20 minutes away from the Henry Street Settlement and able to pick your child up in the event of an emergency. Please notify us immediately if this information changes over the course of the summer.

Emergency Contact 1

Name: Home Phone: L( Work Phone: .... (

~'-=___

_

_

Relationship to Participant: Cell Phone: L( _

---L

_

_

--'

Primary Language Spoken: Yes No

_

Is the Above Person Authorized to Pick-Up My Child at the End of Each Day or in the Event of an Emergency:

Emergency Contact 2

Name: Home Phone: '-( Work Phone: L(

--'

_ '--- _

_

Relationship to Participant: Cell Phone: '-(

......L _

_

Primary Language Spoken: Yes No

_

Is the Above Person Authorized to Pick-Up My Child at the End of Each Day or in the Event of an Emergency:

Emergency Contact 3

Name: Home Phone: .... ( Work Phone: L(

--'

L

_

_

Relationship to Participant: Cell Phone:

L(

---L

_

_

-"-

_

Primary Language Spoken: Yes No

_

Is the Above Person Authorized to Pick-Up My Child at the End of Each Day or in the Event of an Emergency:

Additional Authorized Pick-up

1.

(Name)

2.

(Contact #)

(Relationship)

(Name)

(Contact #)

(Relationship)

Camp Henry Day Camp Rules on Children Walking Home Alone.

A Camper 12 Years and Older will be able to be dismissed from Camp on their own and escort any younger siblings home ONLY if Camp Henry is given written permission from the custodial parent. All other campers must be picked up by the custodial parent or an escort authorized by custodial parent. Campers 12 years and older will not be allowed to escort non family members home, nor will they be able to leave camp until the general camp dismissal time. For all other children, only a parent or guardian or sibling that is 18 or over may pick them up and escort them home. Please Check Off One: I Hereby GIVE my 12-13 year old child permission to go home unescorted: I DO NOT GIVE my 12 - 13 year old child permission to go home unescorted: _ _

Please Check OfI One (If Applicable):

I Hereby GIVE my 12-13 year old child who is a camper permission to escort their younger sibling(s) home: I DO NOT GIVE my 12-13 year old child who is a camper permission to escort their younger sibling(s) home: Younger Sibling 1 Name: _ Younger Sibling 2 Name: _

_

_

The 2011Camp Henry fee is $1,300

Act Now to Take Advantage ofthe Early Bird Special! ! ! !

Check as many that app..ili.

o o o o o

Early Bird Special Full Summer Only Regular Fee Full Summer - 7 wks 1/2 Summer - 4 wks 1/2 Summer - 3 wks Deadline: March 31, 2011 Tues. July 5 - Fri. August 19, 2011 Deadline: July 1, 2011 Tues. July 5 - Fri. August 19,2011 Tues. July 5 - Fri. July 29,2011 Tues. August 1 - Fri. August 19,2011

$1,150

$1,300 $ 745 $ 560

Extended Day $ 150 For an additional fee, you may drop off your child as early as 8 am and pick up your child as late as 6pm. This rate covers you for the full summer July 5, 2011 - August 19,2011. Mini Camp Mon. August 22- Fri. August 26,2011 Extended Day for Mini Camp I would like to donate $20.00 to the Camp Henry Scholarship Fund. (This amount will be added to your tuition.)

TOTAL AMOUNT DUE

Please Note: All payment plans are due in full no later than Friday, July 1,2011.

o

o o

$175 $ 25

$ 20

We accept Money Orders, Cash and Visa, MasterCard and Discover Cards.

We do not accept personal checks.

Credit Card Information

Card Holder's Name: Credit Card Number:

---------------------------

Total Amount: $

- - - Expiration Date: _ / _ / _

_

Cardholder's Signature:

To inquire ahoutfinancial aid, please contact the After-School and Camp Office 212-254-3100, ext 228

Terms and Conditions of Camper Enrollment

1. A deposit of $1 00 must accompany this application. The deposit is for registration and is NOT REFUNDABLE. The tuition payment is due in full no later than Monday, June 7t h, 2010. No child will be permitted to attend camp without payment in full by the above mentioned date. Money Orders should be made out to Henry Street Settlement or we accept Visa or MasterCard credit cards. This excludes debit cards. 2. No child will be properly enrolled in Camp Henry for the 2011 summer without the following paperwork FULLY completed by June 10, 2011: a. Fully completed camp application, b. Accurate and up to date medical form c. Copies of their signed immunization record d. Current insurance card. 3. If child does not attend camp, the entire fee paid to date may be forfeited. No refund will be granted if the camper leaves on hislher own account or is removed from camp due to an inability to adjust or to comply with the camp rules or is unable to function adequately> There is no reduction/refund based on missed days due to absence, illness or to early withdrawal. 4. I am aware that my child must follow the rules and regulations of the summer camp program and may be terminated from Camp Henry ifhe or she does not comply. 5. I hereby consent to the taking of photographs, movies, Internet use, and videotapes, of my child by Henry Street Settlement or its designated representatives. I also grant the right to edit, use, and re-use said products for any and all educational, public service, or not for profit purposes selected by Henry Street Settlement and release any and all rights, title, and interest we or the child may have in said products. Photocopies and facsimiles of this Release and consent shall have the same legal effect as the original.

D Grant Permission D Do NOT Grant Permission

6. Camp Henry is not responsible for any personal items that are lost stolen or damaged while attending camp. 7. I consent that in an emergency Henry Street Settlement may act in loco parentis and obtain medical treatment if necessary. I understand that if medical treatment is deemed necessary I will be informed as soon as possible .

8. I reviewed the application and all the information provided is accurate and true. I agree to all the terms and conditions.

Parent! Guardian Signature Date

Please return to:

Henry Street Settlement

Attn: Camp Services

301 Henry Street 4 th Fl.

New York, NY 10002

Child's Address CitylBorough

·:-k:c--::------,---------'---------..,-----..J........::::~~-----=~~::.:::~~:::..=~:;::::::;:::::::::::====--I

District Phone Numbers

Race (Check ALL that apply) 0 American Indian 0 Asian 0 Black 0 White Native HawaiianlPacilic Islander 0 Other

o

I-:c---::::-:

---=::-:-:_r=c=-_-:-::,---~-_,__..L....,.,___--L------....L---------____::__:_,__----------'-N-U_m_be_r

--1 Home

_

Birth history (age 0-6 yrs)

o Uncomplicated o Complicated by

Allergies

0

Premature:

weeks gestation

Does the child/adolescent have a past or present medical history of the following? Asthma (check severity and attach MAFIAsthma Action Plan): 0 Intermittent 0 Mild Persistent 0 Moderate Persistent 0 Severe Persistent If persistent, check all current medication(s): 0 Inhaled corticosteriod 0 Other controller 0 Quick relief med 0 Oral steroid 0 None

o

o None

o Epi pen presclibed

o Drugs (list)

o Foods (list) o Other (lisO

PHYSICAL EXAMINATION Height _ _ _ _ _ _ _ _ cm Weight _ _ _ _ _ _ _ kg BMI ________ kg/m2

o Attention Delicit Hyperactivity Disorder o Chronic or recurrent otitis media o Congenital or acquired heart disorder o Developmental/learning problem o Diabetes (attach MAF)

o Orthopedic injury/disability o Seizure disorder o Speech, hearing, or visual impairment o Tuberculosis (latent infection or disease) o Other (specity) _

Medications (attach MAF if in-school medication needed) i ! None : J Yes (list below)

Dietary Restrictions None 0 Yes (list below)

o

Explain all checked items above or on addendum

General Appearance:

NI Abnl

HEENT 0 0 Dental 0 0 Neck 0 0 Describe abnormalities:

o o o

Nt Abnl

Nt Abnl

0 0 0

Lymph nodes Lungs Cardiovascular

00 00

00

Abdomen GenitoUlinary Extremities

o o o

NI Abnl

0 0 0

Skin Neurological Back/spine

0 Psychosocial Development [] 0 Language o 0 Behavioral

o

Nt Abnl

DEVELOPMENTAL (age 0-6 yrs) II delay suspected, specify below

o Within normal limits

SCREENING TESTS Blood Lead level (BLL)

(required at age 1yr and 2 yrs and for those at risk)

Date Done

__ 1_ _ 1 _ __ 1_ _ 1 _

Results

Date Done

~g/dL

Results

___ ___

Tuberculosis

Only required tor students entering intermediate!mlddle!junlor or high SChool wfJo have not previously attended any NYC public or private school

__ 1_ _ 1 _ __ 1_ _ 1 _

o o

Cognitive (e,g" play skills) Communication/Language

~g/dL

PPD/Mantoux placed PPD/Mantoux read Interferon Test

induration _ _mm

Lead Risk Assessment

(annually, age 6 mo-6 yrs)

__ 1_ _ 1 _

o At risk (do BLL) o Not at risk o Normal o Abnormal

g/dL

o Neg o Neg o Abnl

ONI

o Pos

OPos Not Indicated

o Social/Emotional o Adaptive/Sell-Help o

Motor

Hearing Pure tone audiometry OOAE

__ 1 _ _ 1 _

o

__ 1 _ _ 1 _

Chest x-ray

(if PPO or Interferon positive)

__ 1_ _ ' _ _

o

- Head Start Only - Hemoglobin or Hematocrit (age ~12 mol Vision

(reqUired tor new school entrants _ _ 1 _ _ 1 _ and children age 4-7 yrs)

Acuity Right _

__ 1_ _ 1 _

%

o with glasses

/ /Strabismus 0 No 0 Yes

Left -

IMMUNIZATIONS DATES

CIR Number 01 Child _--i_....L_-"-_-'-_-'-_.L._-'--_'---_

__1 _ _ 1_ _ __ 1_ _ 1 _ __ I _ _ __ 1_ _' _

I

Inlluenza MMR Valicella Td Tdap __ I _ _ I_~ Meningococcal HPV Other, specity: ASSESSMENT

__1 _ _ 1 _

__ /-=--_1 __ -

__ 1_ _ 1_ _

__ 1_ _ 1_ _ __ 1_ _ 1 _

HepB __ 1 _ _1 _ _ Rotavirus DTP/DTaPIDT Hib PCV __ 1_ _ 1 __ 1_ _ 1 _ _

__ I _ _ 1_ _

__ ' _ _ 1 __ ' _ _ 1

i-__

__1 _ _1 _

__1 _ _ 1_ _ __1 _ _ 1_ _

~I

1_ _ 1 _ _ 1_ _ 1 _ _

__ 1_ _ 1 _

__ 1_ _ 1

1_ _ 1_ _

/~_I'-_

HepA

__ 1 _ _ 1 _

__ I _ _ i

__ 1_ _ 1_ _

1_ _ 1 __1 _ _ 1 _ _ 1_ _ 1

1_ _ 1 __1 _ _ 1 _ _ 1_ _ 1

__ I__

__1 _ _ 1_ _ 1_ _ 1_ _

Polio __ 1_ _ 1 RECOMMENDATIONS Restrictions (specffy) Follow-up Needed Referral(s):

__ 1_ _ 1_ _ ,

_ _1_

:::: Full physical activity

0 Full diet

:::: Well Child (V20,2)

0 Diagnoses/Problems (fist)

ICD-9 Code

0 No

0 Yes, for

:::: Special Education

Appt. date:

[J Dental

_._1 _

_

I _._

0 None

[J Early Intervention

C Vision

I I Other

Health Care Provider Signature Health Gare Provider Name and Degree (pnno Date Provider Ucense No, and State · ,PROVIDER .J.D. · ,

1-;--:;::--;:--------------------+.:-.,,---:-::----:-:----:-:---::::---:::=-------1 CooimeIJIs· Facility Name National Provider Identifier (NPI)

Address Telephone

(---)-------

CH-205 (5108)

City

Slate

Zip

I

Fax

I

(---)-------

Copjes: While SChooVChild GarelEarty Inte""'nlicniCamp, Canary Health Care Provider, Pink ParentlGuardian

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