Higher Learning – The Musical (Summer Camp)
Event on 2016-07-07 14:00:00
RYO Member Last Name, First Initial Higher Learning – The Musical – Camp Registration Form Please print clearly. Please complete all blanks on this form. If there is a blank that is not applicable, please write N/A in that blank. Incomplete forms cannot be accepted and we are unable to provide care until all paperwork has been submitted. If you have any questions about completing this form, please contact your local Revisions branch. Print completed registration form, sign all applicable pages & bring to your Revisions branch to complete registration. Child’s Information: Member # ____________ Parent/Guardian and Medical information: In the evAt the camp director’s discretion, campers that receive 3 written warnings during a session may be asked to leave the program for the remainder of the session. Authorized Person for pick-up (in addition to parents and emergency contacts) Person(s) NOT authorized for pick-up (appropriate legal paperwork must be on file when the custodial parent requests not to release the child to the other parent) School and Child Care Centers previously attended Does your child have any allergies and/or intolerances to food, medication or any other substances? What are the symptoms and action to be taken if any? Please provide information on any chronic physical problems and pertinent developmental information and any special accommodations needed. Attach additional sheets if necessary. Check here if your child will be required to take medication during the camp day AND complete Medication Authorization Forms Parent Statement of Understanding The following information is important for the safety and protection of your child. Please read this information and sign below. I understand that my child will not be released to any person(s) not listed on the enrollment form. I understand that my child will not be released to any person(s) who seems to be under the influence of drugs or alcohol. I understand that I am not to leave my child at the Revisions or program site unless a Revisions Camp staff member or volunteer is there to receive and supervise my child. I understand that it is my responsibility to sign my child in the morning and sign my child out before leaving in the afternoon. Sign-in/Sign-out sheets are available as you arrive at the program area. (See other pick-up provisions in Parent Handbook). I understand that my child will not be allowed to leave the program with an unauthorized person. Any person authorized to pick up my child must be listed on this form. Authorization by telephone will not be accepted. I understand that the Revisions is mandated to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation. I understand that Revisions staff and volunteers are not allowed to babysit or transport children at any time outside the Revisions facilities and program. If a violation of this policy is discovered, the Revisions will take immediate disciplinary action toward staff and volunteers. I have read and understand the statements above regarding Revisions policies and procedures. I have received a copy of the Revisions Parent Handbook. Copies are available at your local Revisions branch. I have provided a copy of either a) my child’s physical and immunization records (for camps in VRGINIA) or b) “Camper Health History” (for camps in Maryland) along with this form. Statement of Authorization 1. My child has permission to be transported by a Revisions vehicle and to participate in all Revisions program activities and related field trips. 2. My child has permission to participate in swimming activities. Assess your child’s swimming abilities here: The Revisions reserves the right to assess your child before any activities In the case that your child becomes ill during the program, you will be contacted as soon as possible. If the parent or guardian is unable to be reached, the child’s emergency contact will be notified. It is the responsibility of the parents or guardians to arrange for the child to be picked up from the center as soon as possible. In the case that your camper or anyone in the immediate household of the camper develops a reportable communicable disease as defined by the State Board of Health, it is the responsibility of the parent to notify the Revisions within 24 hours or the next business day in order for the Revisions to take proper action, except in the case of life-threatening diseases which must be reported immediately. My signature authorizes the management and staff of the Revisions of Metropolitan Washington to act for me according to their best judgment in the event of a medical emergency and/or routine medical care. I/we grant permission for emergency medical treatment and/or routine medical care by the Revisions camp staff, a rescue squad, or private physician and/or hospital or emergency health care facility staff, under the same circumstances as above, if needed. Any such action will be taken in the best interest of my child and will be reported to me/us as soon as possible. My signature waives and/or releases the Revisions of Metropolitan Washington from any and all liability and/or financial responsibility for any medical expenses incurred. The parent/guardian authorizes the application of sunscreen for his or her child by Revisions staff. (please note any adverse reaction to sunscreen of which you may be aware) Brand? ________________________________________________________________________________ The parent/guardian authorizes the application of insect repellent for his or her child by Revisions staff. (please note any adverse reaction to sunscreen of which you may be aware) Brand? __________________________________________________________________________ By signing below, you are authorizing all of the above. FOR VIRGINIA CAMPS ONLY! Proof of child’s identity and age may include a certified copy of the child’s birth certificate, birth registration card, notification of birth (hospital, physician or midwife record), passport, copy of the placement agreement or other proof of the child’s identity from a child placing agency (foster case and adoption agencies), record from public school in Virginia, certification by a principal or his designee of a public school in the US that a certified copy of the child’s birth record was previously presented or copy of entrustment agreement conferring temporary legal custody of a child to an independent foster parent. While programs are not required to keep the proof of child’s identity, documentation of viewing this information must be maintained for each child. Revisions Kids for Character Pledge I pledge to be a kid for character. I will be worthy of trust. I will be respectful and responsible, doing what I must. I will show that I care for those around me. I will always do my share. I will believe in myself. Camper’s Signature Date Behavior Agreement At the Revisions we take the happiness of your children very seriously. We want every day here to become a happy memory for them. Therefore, we work hard at creating an environment that will allow this to happen. Along with our efforts, we need the children to help us create that environment by following some simple, but effective rules. Below is our Behavior Agreement, please read over it with your child and be sure they understand what it is and why they are signing it. This will help us help them have a wonderful experience at Revisions Summer Camp! Thank you! I will listen to the staff and follow their directions. I will respect other people’s belongings by not touching/using their stuff without permission. I will not hit or fight other people. I will not yell while inside the campsite building and will use my inside voice when speaking. I will use appropriate language. Which does not include swear words or negative remarks. (i.e. “Shut up,” “Stupid,” “Dumb,” etc…) Before leaving the room, I will ask a staff member for permission. I will respect other’s feelings by having a positive attitude when talking to them and not talking to others. Not abiding by these rules can result in suspension from the program. All incidents will be handled on a 3 incident system, except hitting/fighting. Hitting/fighting will be an immediate 1-day suspension from the program. All other incidents will be handled as follows: At the camp director’s discretion, campers that receive 3 written warnings during a session may be asked to leave the program for the remainder of the session. -1st Incident: -2nd Incident: -3rd Incident: VERBAL WARNING WRITTEN WARNING/PARENT MEETING 1-DAY SUSPENSION Parent/Guardian Signature Date Camper’s Signature Date Revisions OF CSRA (“Revisions”) PARTICIPANT WAIVER FORM ACKNOWLEDGEMENT I expressly acknowledge that there are certain dangers, risks, illnesses and personal injuries inherent in participating in the Revisions’s programs, events, classes, and/or other activities, which may result from unavoidable accidents or injuries, athletic activities, sports programs/classes, the use of any equipment, exercise, or other activities or from my or my minor child(ren)’s or ward(s)’ physical condition. I understand that the Revisions and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns assume no responsibility for loss, damage, illness or injury to person or property that I or my minor child(ren) or ward(s), if applicable, may sustain as a result of my or their physical condition or resulting from my or their participation in any activities, programs, events, classes, the use or non-use of any equipment, exercise, horseback riding, archery, field trips, waterfront and pool activities, canoeing/boating, campfires, hiking, high ropes and other challenge courses, or any other activities, classes, events, or programs at and/or sponsored by the Revisions. I expressly acknowledge, on behalf of myself and my minor child(ren) and ward(s), heirs and executors, that I voluntarily assume the sole risk for any and all dangers, illnesses and personal injuries that may result from my or my minor child(ren)’s or ward(s)’ participation in any events/activities/programs/classes while at the Revisions and/or sponsored by the Revisions. I also acknowledge that the Revisions often uses photographs, videotapes, television programs, motion pictures, tape recordings, or other similar media for promotional purposes. I hereby consent to the use of my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es) in such materials to be exhibited and used for advertising, trade purposes, solicitation of patronage, promotional purposes, or other similar purposes, even if my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es) are an integral part of such photograph, videotape, television program, motion picture, tape recording, or other similar media. RELEASE In consideration of the Revisions allowing me and/or my minor child(ren) or ward(s) to attend and/or participate in any programs, events, classes, or other activities at the Revisions and/or sponsored by the Revisions, I hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, release and forever discharge the Revisions and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns, from and against any and all rights and claims for any loss, damage, illness or injuries to person or property sustained as a result of my attendance and/or participation in any such programs, events, classes, and other activities, whether or not such loss, damage or injury results from the negligence of the Revisions and its employees, agents, or representatives or from some other cause. My agreement to release the Revisions does not include any loss, damage or injury that results from the Revisions's gross negligence or willful, wanton, or reckless misconduct. I further waive any and all rights to inspect or approve the photograph, videotape, television program, motion picture, tape recording or other use of my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es), including any written article, script, caption or other writing that may accompany such use of my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es). I hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, release and forever discharge the Revisions and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns, from and against any and all liability, claims, losses, costs, expenses or damages for libel, slander, invasion of privacy, conversion, defamation, appropriation of likeness or any other claim based on the use of my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es) in any such materials. INDEMNIFICATION I hereby represent and warrant to the Revisions that I have the authority to execute this Participant Waiver Form on behalf of myself and/or on behalf of my minor child(ren) or ward(s) as parent, guardian and/or next friend, if applicable. In the event of any misrepresentation or breach of the foregoing warranty by me, or in the event that I, my minor child(ren) or ward(s), or any other person nevertheless asserts any claim against the Revisions arising out of my or my minor child(ren)’s or ward(s)’ participation in any program, event, class or other activity as set forth herein, I agree to indemnify, hold harmless and defend the Revisions from and against any and all liability, claims, losses, costs, expenses or damages resulting therefrom, including, but not limited to, claims of loss, damage, illness or injury to person or property whether or not such loss, damage, illness or injury results from the negligence of the Revisions or from some other cause. ACCEPTANCE I expressly acknowledge and agree to the terms and conditions set forth on this Participant Waiver Form.
at Rose Of Sharon Baptist Church
1126 Florence St
Augusta, United States