2016 SUMMER CAMP REGISTRATION APPLICATION PARENT RESPONSIBILITY CONTRACT HOURS • Kids’ Korner/Teen Scene Summer Camp is open Monday – Friday from 6:30 a.m. to 6:00 p.m., closed on July 4th. Opportunities for Learning sites are closed from 8:00 a.m. to 12:15 p.m. while students are in class. ATTENDANCE / ABSENCES / ILLNESS • Daily attendance is not required, but must be consistent with contracted Camp schedule. Parents must notify the Summer Camp staff in advance of any additional days of attendance. If your student is absent for any reason on a contracted day of attendance please report it to the Supervisor no later than 7:00 a.m. on the day of the absence. • If a student becomes ill or is injured, the parent will be notified immediately and is expected to pick up the student promptly. In the case of an emergency, the staff will take any necessary action for the health and safety of the student. SIGN IN AND OUT PROCEDURES • Each student must be signed in and out each day by a parent or an adult authorized by the parents. A valid photo ID must be presented prior to taking a student from Summer Camp. The authorized adult must be eighteen years or older unless Kids’ Korner/Teen Scene has a signed waiver on file. This procedure must be adhered to for your student’s safety. • To ensure the safety and welfare of students, a copy of any legal documents regarding issues between parents or guardians should be on file with the Kids’ Korner/Teen Scene Supervisor. The Supervisor’s responsibility is to enforce documentation. Students will be dismissed from the program if problems between parents cannot be worked out without disruption to the program. If there is a custody arrangement, the parent who has custody on their assigned day has the right to authorize who is able to pick up the student unless there is a court order stipulating otherwise. Both parents are entitled to their child’s records. DISCIPLINE PROCEDURES • Students are held accountable to the same high standards of behavior implemented during the school day. A student whose behavior disrupts the program and prevents the program from being beneficial to him/her or others may be dismissed from the program. PERSONAL ITEMS • Kids’ Korner/Teen Scene will not be responsible for any personal items or electronic devices broken, lost or stolen. • Cell phone use will be limited to calling home or in case of an emergency. FEES AND TUITION Summer Camp tuition and a non-refundable registration fee of $50 (early registration discount) are due by June 1st, along with completed enrollment forms, on or after June 1st registration will be $65. There are no reductions in tuition due to days missed, including suspensions from summer camp or illness. Sibling discounts are available. All returned or re-deposited checks will be charged a $30.00 fee. Overtime charges for late pickup beyond the 6:00 p.m. closing time will be assessed at the rate of $1.00 per child for each minute past 6:00 p.m. Any student not picked up within a reasonable time after closing (not to exceed 45 minutes), when no effort has been made by the parent to notify the center that the student will be picked up late, will be placed in the care of the local Sheriff/Police Department. NUTRITION A snack will be provided in the morning and afternoon. Page 1 of 6
Summer Camp Application
2016 SUMMER CAMP REGISTRATION APPLICATION SUMMER CAMP PAYMENT AND ACTIVITIES SCHEDULE
REGISTRATION Before June 1st - $50.00, early registration discount On or After June 1st - $65.00
PAYMENT DUE Week 1 Week 2 Week Week Week Week Week Week Week Week
FEES Tuition is due weekly. Payments are to be made on Mondays 1-3 days per week Covina Ed Center - $115, OFL - $80 4-5 days per week Covina Ed Center - $135, OFL - $95
ACTIVITIES
Monday, June 13th Monday, June 20th
Edward’s Theatre, McDonald’s, and Kelby Park Chuck E. Cheese, Covina Library, Taco Bell, and Cougar Park Marine life movie, Glow in the Dark Party, Police/Fire 3 Monday, June 27th Department assembly th Edward’s Theatre, Wendy’s*, Pizza**, Kelby*/Palm View**/ Tuesday, July 5 4 (Closed - Monday, July 4th) Hollenbeck**/Barranca** Park Walnut Creek, McDonald’s tour, Cougar Park*, Palm View** 5 Monday, July 11th /Hollenbeck**/Barranca** Park Grocery store*/Home Depot** visit, Burger King*/Jack in the 6 Monday, July 18th Box**, Kelby Park*, Palm View Park**/Hollenbeck Park**/ Barranca Park** 7 Monday, July 25th Cougar Park*, Covina Bowl ** st 8 Monday, August 1 Cabrillo Marine Aquarium, Taco Bell, Cougar Park th 9 Monday, August 8 Castle Park, In-N-Out Burger, Kelby Park th 10 Monday, August 15 Battleship Iowa Museum, Wendy’s, Bubble Day, Pajama Party
Covina Education Center 1–3 4–5 Days Days $115 $135 $115 $135
Opportunities for Learning 1–3 4–5 Days Days
$115
$135
$115
$135
$80
$95
$115
$135
$80
$95
$115
$135
$80
$95
$115 $115 $115 $115
$135 $135 $135 $135
$80
$95
* – Covina Education Center Summer Camp Students ** - Opportunities for Learning Students
Mondays – Chef’s Hat and Media Center Fridays – Water Day
Students attending an Opportunities for Learning course will remain at school site of attendance and may attend different destinations due to distance. When courses are over, all students will report to Covina Education Center for Summer Camp. All trips are subject to change. Summer Camp - June 13th – August 19th Covina Education Center: Room 8 160 N. Barranca Ave. Covina, CA 91723 626.974.4223
Covina Education Center Child Development Office - Rm 5 160 N. Barranca Ave. Covina, CA 91723 626.974.7600, extension 2083
Opportunities for Learning – July 5th – July 29th ONLY Grovecenter Elementary – Room 25 Las Palmas – Room 1 775 N. Lark Ellen Ave. 641 N. Lark Ellen Ave. West Covina, CA 91790 Covina, CA 91722 626.974.4424 626.974.7428
Opportunities for Learning Barranca Elementary – Room 17 727 S. Barranca Avenue Covina, CA 91723 626.974.4020
– July 5th – July 29th ONLY Cypress Elementary – Room 23 315 W. Cypress St. Covina, CA 91723 626.974.4320
Opportunities for Learning – July 5th – July 29th ONLY Sierra Vista Traweek – Room 12 1941 E Rowland 777 E. Puente Ave. West Covina, CA 91791 Covina, CA 91790 626.974.7428 626.974.7428
Must receive 12 students, if not, students will be bussed to Traweek. Page 2 of 6
Summer Camp Application
2016 SUMMER CAMP REGISTRATION APPLICATION
COVINA EDUCATION CENTER
Summer Camp June 13th – August 19th, 6:30 a.m. – 6:00 p.m.
Covina Education Center
ROOM 8 ROOM 5
Covina-Valley Unified School District
SUMMER CAMP ATTENDANCE Please cross out any days your student WILL NOT ATTEND Summer Camp. Camp will be closed Monday, July 4th in observance of Independence Day.
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Page 3 of 6
Summer Camp Application
STUDENT INFORMATION LAST NAME BIRTHDATE MOTHER FATHER
FIRST NAME YES NO OFL COURSE YES NO
FEMALE MALE GENDER
PARENTS GUARDIAN
STUDENT LIVES WITH
MIDDLE SITE
CUSTODY ALERT
ADDRESS
YES NO
ALLERGIES
HOME PHONE
APT
CITY
ZIP CODE
PARENT / GUARDIAN INFORMATION
FATHER
STEPFATHER
NAME
STEPMOTHER
GUARDIAN
PRIMARY PHONE/CELL
HOME ADDRESS
MOTHER
APT
YES
NO BILL ME EMPLOYER
CVUSD EMPLOYEE
SECONDARY PHONE/CELL CITY
ZIP CODE
_________ %
$ _________ PERCENTAGE / AMOUNT
IF NO, BILL (NAME)
EMPLOYER ADDRESS
EMAIL ADDRESS
CITY
WORK PHONE
PARENT / GUARDIAN INFORMATION
MOTHER
STEPMOTHER
NAME
STEPFATHER
GUARDIAN
PRIMARY PHONE/CELL
HOME ADDRESS
FATHER
IF NO, BILL (NAME)
EMPLOYER
CVUSD EMPLOYEE
SECONDARY PHONE/CELL
APT
CITY
YES
NO BILL ME
ZIP CODE
_________ %
$ _________ PERCENTAGE / AMOUNT
EMPLOYER ADDRESS
CITY
EMAIL ADDRESS WORK PHONE
SUBSIDIES ONLY NAME OF SUBSIDY
CONTACT PERSON
AMOUNT PAID BY SUBSIDY
PARENT FEE AMOUNT
$
PHONE NUMBER
$
EFFECTIVE DATE
OFFICE USE ONLY START DATE INSURANCE COPY
YES NO
AMOUNT PAID PHOTO
YES NO
SHIRT SIZE
_____
Page 4 of 6
RECEIPT NUMBER NO G NO PG NO PG-13
BILLING INFORMATION CASH: $ ___________________ CHECK/MO: _________________
Summer Camp Application
2016 SUMMER CAMP REGISTRATION APPLICATION PICKUP / RELEASE / EMERGENCY CONTACTS NAME
RELATIONSHIP
PRIMARY PHONE/CELL
SECONDARY PHONE/CELL
NAME
RELATIONSHIP
PRIMARY PHONE/CELL
SECONDARY PHONE/CELL
NAME
RELATIONSHIP
PRIMARY PHONE/CELL
SECONDARY PHONE/CELL
NAME
RELATIONSHIP
PRIMARY PHONE/CELL
SECONDARY PHONE/CELL
STUDENTS WILL ONLY BE RELEASED TO INDIVIDUALS EIGHTEEN (18) YEARS OR OLDER UNLESS KIDS’ KORNER/ TEEN SCENE HAS A SIGNED WAIVER ON FILE.
PARENT / GUARDIAN SIGNATURE
DATE
SIBLING INFORMATION
NAME
BIRTHDATE
GRADE
SCHOOL
NAME
BIRTHDATE
GRADE
SCHOOL
NAME
BIRTHDATE
GRADE
SCHOOL
YES NO SUMMER CAMP YES NO SUMMER CAMP YES NO SUMMER CAMP
PERMISSION FOR MEDICAL TREATMENT In the event my child ______________________________ becomes ill or injured while attending Summer Camp Enrichment Program, or while participating in a field trip, a reasonable attempt will be made by the Child Care staff to contact the parent/ legal guardians or other individuals designated by me. Should no one be reached, I hereby give my consent to have the Kids’ Korner/Teen Scene Child Care staff give approval for whatever x-ray, medical treatment authorization, anesthetic, medical, dental, or surgical diagnosis and/or treatment and hospital care from a licensed physician and/or surgeon as deemed necessary for my child’s safety and welfare. In addition, I give the Kids’ Korner/Teen Scene Enrichment staff permission to consult Dr. __________________________ at phone number (______) ____________________ and/or contact the nearest hospital and, if necessary, to arrange transportation for my child to the doctor’s office or any emergency center. It is understood that the resulting expenses will be the responsibility of legal guardians/parents/myself. DOES YOUR CHILD HAVE ANY MEDICAL OR FOOD ALLERGIES, PHYSICAL DISABILITIES, OR INDIVIDUAL NEEDS? YES NO
PARENT / GUARDIAN SIGNATURE
HEALTH ALERT
DATE
PROOF OF INSURANCE As you enroll your student for Summer Camp you are required to provide proof of accidental medical insurance for your student. Contact your school office for insurance purchase information if needed.
PARENT / GUARDIAN SIGNATURE
DATE
CAMP SHIRTS Kids’ Korner / Teen Scene will provide a Covina-Valley Summer Camp t-shirt for students. It is mandatory that students wear the t-shirt while attending field trip outings Please circle your student’s shirt size:
Youth sizes Adult Sizes Page 5 of 6
Small Small
Medium Medium
Large Large Summer Camp Application
2016 SUMMER CAMP REGISTRATION APPLICATION PHOTOGRAPHY RELEASE We would like your permission to videotape and/or photograph your child, without compensation, either individually or together with other children, parents, and staff members associated with Summer Camp. With this permission, we ask you to assign to Covina-Valley Unified School District an absolute copyright and/or the right to copyright such videos and photographs, and the right to use your child’s picture, portrait, or photograph in all forms of media and in all manner, including electronic print, digital, or electronic publishing via the internet, and/or composite representation for the publication processes related to Kids’ Korner/Teen Scene Enrichment Program.
STUDENT’S NAME YES, I authorize my child to be photographed NO, I do not authorize my child to be photographed, and agree to assign the foregoing rights, and nor do I assign the right in the above release. approve the above release.
PARENT / GUARDIAN SIGNATURE
DATE
MOVIE RELEASE Summer Camp shows movies on an occasional basis. Movies most commonly shown to all children in our program are rated “G”. Occasionally, with parent/legal guardian’s approval, a movie that is rated “PG” will be shown. If you do not wish for your child to view a particular movie, please notify staff and another activity will be provided.
STUDENT’S NAME YES, I authorize my student to view “G” rated movies. YES, I authorize my student to view “PG” rated movies.
NO, I do not authorize my student to view “G” rated movies. NO, I do not authorize my student to view “PG” rated movies.
PARENT / GUARDIAN SIGNATURE
DATE
STUDENT’S PORTION My parent/guardian has reviewed the behavior section of Child Care Policies and Regulations in the Parent Handbook with me. I understand them and agree to follow them
STUDENT’S NAME (PLEASE PRINT)
STUDENT’S SIGNATURE
PARENT’S PORTION I have read, understand, and agree to abide by the rules of operation for Summer Camp and follow the policies and regulations within the application and Parent Handbook established by the Covina-Valley Unified School District Summer Program and enroll my student(s) as per the Fee Schedule. I further understand these policies and regulations may be modified during summer. (One signature required, unless student lives in more than one household, in which event, both signatures are required.)
PARENT/GUARDIAN’S SIGNATURE
DATE
PARENT/GUARDIAN’S SIGNATURE
DATE
APPLICATION VERIFICATION I hereby verify that all of the information on this application is true and correct to the best of my knowledge and can be shared with appropriate staff in order to provide a safe environment for my child.
PARENT/GUARDIAN’S SIGNATURE
DATE Page 6 of 6
Summer Camp Application