Authorization Form to Pick Up Something

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					                           Boys and Girls Clubs of Southern Rensselaer County
                                          2011 Camp Adventure

                                         Registration Packet and Check List

To register, this packet and all forms must be completed in their entirety, submitted TOGETHER along with a 25% deposit
of all session fees for which you are applying.

***No Registration will be considered complete and approved until all forms and fees are
submitted and verified accurate. Registration is on a First Come, First Serve Basis.***
Campers whose session is not paid in full prior to their start date will not be allowed on the bus to camp or to be dropped off
at camp or the club.

LATE REGISTRATION: All applications must be submitted by the Wednesday before the session begins.
– NO EXCEPTIONS. NO applications will be accepted after then.

List of all forms required to register your child for Camp Adventure. Please submit all paperwork with your deposit.
    o Current Club membership (if not current, complete membership form and pay membership fee)
    o Camp Registration Form
    o Pick Up and Bus Stop Authorization Form – only complete if needed.
    o 2011 Camp Health Record and Immunization Record
    o Camp Adventure Policy and Behavior Acknowledgement
    o Camper Questionnaire

Camp Hours: 7am-5:30pm Bus leaves Club at 9:30 AM SHARP , leaves Camp at 4:30 PM and returns at 5:00 PM.

Camp Dates:                                     Family Day is Sunday, August 21st
Week 1: Monday, June 27th to Friday, July 1st
Week 2: Tuesday, July 5th to Friday, July 8th (Closed Monday for Independence Day)
Week 3: Monday, July 11th to Friday, July 15th
Week 4: Monday, July 18th to Friday, July 22nd
Week 5: Monday, July 25th to Friday, July 29th
Week 6: Monday, August 1st to Friday, August 5th
Week 7: Monday, August 8th to Friday, August 12th
Week 8: Monday, August 15th to Friday, August 19th

       Bus Leaves Club at 9:30am Sharp, arrives to Camp at 10:00
       Bus Leaves Camp at 4:30pm, arrives to Club at 5pm.
       All campers must be picked up by 4:30pm at CAMP or by 5:30pm at CLUB.
        ***: Campers who are not picked up by 4:30pm at CAMP will be put on the bus back to the CLUB and will need to
be picked up from the CLUB by 5:30pm.***
                        Daily Camp Schedule

***All campers are required to bring a bathing suit and towel
EVERYDAY with them to camp, along with a water bottle.
***Flip flops are not allowed to be worn at camp.

7am-9am                 Drop off at CLUB ONLY. Light Breakfast served at 8am.
8am                     Regular drop off at CAMP begins
9:30am Sharp            Bus leaves club, heading to camp
10am                    Bus arrives at camp
10:05am                 Welcome/Announcements
10:15am                 Activity (Swim lesson, Sports, A&C, or Nature)
11:15am                 Activity (Swim lesson, Sports, A&C, or Nature)
12:00pm                 Lunch
12:45pm                 Group Choice
1:45pm                  Camper Choice
2:45pm                  All Camp
3:45pm                  Snack
4:00pm                  Group Kaper (Chore)
4:15pm                  Circle/Group Games & get ready for bus
4:30pm                  Bus leaves Camp
***ALL campers being picked up at CAMP must do so by 4:30pm***
5:00pm                  Bus arrives at Club

5:30pm ***ALL campers must be picked up from the CLUB by 5:30pm***


Contact Information:
Camp Phone Number – (518) 674-0127
Club Phone Number – (518) 465-3403    Club Fax Number – (518) 465-3973




**Please keep this sheet for your information.
                     BOYS & GIRLS CLUBS OF SOUTHERN RENSSELAER COUNTY
                            CAMP                                                        For Office Use Only:
                          ADVENTURE                                                     Membership # _________Expiration_________
                     2011 REGISTRATION FORM
                                                                                        Deposit Amount           $__________________
                                                                                        Week(s) Attending:          1 2 3 4 5 6 7 8
ALL CAMPERS MUST BE OR BECOME MEMBERS OF THE BOYS AND
GIRLS CLUBS OF SOUTHERN RENSSELAER COUNTY

Camper’s Full Name _______________________                                                               __________________________
Current Age ___                    _          Grade Entering                              Date of Birth ______                      ______
Camper’s Address ________________________________________ City__________________________ State_______ Zip________
Mother’s Name _________________________________________ Employer __________________________________________
Best Contact Phone Numbers 1.______________________ 2.__________________________ 3.___________________________
Father’s Name _________________________________________ Employer ___________________________________________
Best Contact Phone Numbers 1.______________________ 2.__________________________ 3.___________________________
Camper lives with ____Mother ____ Father ____Both. If not both, please provide accurate information as to who is legal guardian.
Guardian’s Name _______________________________________________________Phone________________________________
Address ___________________________________________________________________________________________________
       Please indicate which week(s) you wish your child to attend and where they will be dropped off – (A light breakfast is included).
                                                 Morning drop off location:       OR       Bus Stop Route

____Week #1 June 27 – July 1, 2011 . . . . . . .        _____ Club _____ Camp                          ____ Bus pick up en-route
____Week #2 July 5 – July 8, 2011. . . . . . . . .      _____ Club _____ Camp                          ____ Bus pick up en-route
____Week #3 July 11 – July 15, 2011. . . . . . .        _____ Club _____ Camp                          ____ Bus pick up en-route
____Week #4 July 18 – July 22, 2011 . . . . . .         _____ Club _____ Camp                          ____ Bus pick up en-route
____Week #5, July 25 – July 29, 2011. . . . . .         _____ Club _____ Camp                          ____ Bus pick up en-route
____Week #6 August 1 – August 5, 2011 . . .             _____ Club _____ Camp                          ____ Bus pick up en-route
____Week #7, August 8 - August 12, 2011. . .            _____ Club _____ Camp                          ____ Bus pick up en-route
____Week # 8 August 15 – August 19, 2011 ..             _____ Club _____ Camp                          ____ Bus pick up en-route
COST:
$150.00 per week. Applications will not be accepted after the Wednesday before the session begins.

          (A deposit of 25% of each session is due upon registration-this will be applied to each session that the child attends.
          If the child does not attend NO refunds will be made.)

Limited financial aid is available with proof of income. If you are in need of assistance please submit Camp Adventure Financial Aid Form (yellow)
with this application, available upon request from Club Office. FULL CAMPERSHIPS ARE VERY LIMITED AND WILL ONLY BE AWARDED IN
EXTREME CASES. All others will be required to pay adjusted amounts before camp sessions begin.

*******************************************************************************************************************************************
I understand the fee schedule for each session and that said fees are due prior to the start of each session. I also understand that if all fees are
not paid prior to the start of the session, the health record is not submitted, and the registration is not complete, my child will not be able to attend
Camp Adventure. THIS RULE WILL BE STRICTLY ENFORCED; NO EXCEPTIONS. No refunds will be given after the session begins.
I have read and understand the information contained in this application and agree to the conditions as set forth. The information I have
provided is true and accurate to the best of my knowledge.


________________________________________________________                                          ________________________________
          Signature of Parent/Guardian                                                                             Date
                                            EMERGENCY CONTACTS
                                    And Authorized Release (pick-up) of a child


                           Member Name: ____________________________________________
                     PRIMARY CONTACT                                              SECONDARY CONTACT
Relationship to Member: (Parent 1) ____________________       Relationship to Member: (Parent 2) ____________________
Name: ____________________________________________            Name:____________________________________________
Address: (Home) ___________________________________           Address: (Home) ___________________________________
Phone: (Home) _____________________________________           Phone: Home) _____________________________________
Phone: (Cell) ______________________________________          Phone: (Cell) ______________________________________
Employer: ________________________________________            Employer:_________________________________________
Address: (Work) ____________________________________          Address: (Work) ___________________________________
Phone: (Work)______________________________________           Phone: (Work) _____________________________________
Email: ____________________________________________           Email: ___________________________________________

       This person can pick up my child. (Please check)              This person can pick up my child. (Please check)
                    EMERGENCY CONTACT                                             EMERGENCY CONTACT
Relationship to Member: _____________________________         Relationship to Member: ____________________________
Name:____________________________________________             Name:____________________________________________
Address: (Home) ___________________________________           Address: (Home) ___________________________________
Phone: Home) _____________________________________            Phone: Home) _____________________________________
Phone: (Cell) ______________________________________          Phone: (Cell) ______________________________________
Employer:_________________________________________            Employer:_________________________________________
Address: (Work) ___________________________________           Address: (Work) ___________________________________
Phone: (Work) _____________________________________           Phone: (Work) _____________________________________
Email: ___________________________________________            Email: ___________________________________________

           This person can pick up my child. (Please check)             This person can pick up my child. (Please check)
                    EMERGENCY CONTACT                                             EMERGENCY CONTACT
Relationship to Member: ____________________________          Relationship to Member: _____________________________
Name:____________________________________________             Name:____________________________________________
Address: (Home) ___________________________________           Address: (Home) ___________________________________
Phone: Home) _____________________________________            Phone: Home) _____________________________________
Phone: (Cell) ______________________________________          Phone: (Cell) ______________________________________
Employer:_________________________________________            Employer:_________________________________________
Address: (Work) ___________________________________           Address: (Work) ___________________________________
Phone: (Work) _____________________________________           Phone: (Work) _____________________________________
Email: ___________________________________________            Email: ___________________________________________

           This person can pick up my child. (Please check)             This person can pick up my child. (Please check)
                                                 BUS ROUTE INFORMATION




Route # 1: Rensselaer/West Sand Lake: The bus leaves the Club at 9:30am, goes North on Broadway to Washington
Ave. The bus continues on Washington Ave out of the city of Rensselaer and crosses Route 4 in North Greenbush and onto
Route 43 East. The bus then continues East on Rt. 43 through Sand Lake and into Averill Park. In Averill Park we bear right
on Eastern Union Turnpike until you come to Holcomb Road, at which you will take a right. From Holcomb road, the bus
continues to go straight until reaching 2nd Dike road, we turn right on 2nd Dyke Road, upon which we take an immediate left
into Camp Adventure

(Tentative) Route # 2: East Greenbush/Schodack: The bus leaves the Club at 9:30am, goes South on Broadway to
Columbia Turnpike (9&20), turns left on 9&20. The bus continues on 9&20 until turning left onto Rt. 150, heading north, then
a right turn onto Miller’s Corners. Then a left on Burden Lake Rd, then a right on 2 nd Dyke road, then a right into Camp
Adventure.




AUTHORIZED RELEASE AT DESIGNATED BUS STOP
(This form is for campers who are picked up from home and/or dropped off at home by the bus. If the child is taking the bus
ONLY from the Club to Camp AND from Camp to the Club, this form does not need to be filled out.)


I hereby authorized the staff of Camp Adventure, a division of the Boys & Girls Clubs of Southern Rensselaer
County, to drop off my child at the following location:


Place of designated bus drop off:__________________________________________________



I realize that it is my responsibility to make sure my child reaches their destination safely from this drop off point. Should I
deem it necessary, it is my responsibility to make sure proper supervision is there to meet my child at the bus. Further, I
realize that once my child is dropped off, the staff of Camp Adventure is no longer responsible for the welfare and safety of
my child.

___________________________________________                                   ___________________________
Parent/Guardian Signature                                                     Date

  IF THERE IS TO BE A CHANGE IN THE PICK-UP/DROP-OFF POINTS OF YOUR CHILD(REN), YOU MUST NOTIFY
                                 THE STAFF IN ADVANCE IN WRITING.
                                                                 CAMP ADVENTURE
                                                                 2011 Health Record



Camper’s Name:_______________________________________________________Date of Birth____________________
Address:_____________________________________________________________Phone_________________________
Parent/Guardian’s Name________________________________________________Phone (Day)____________________
Place of Employment:
Mother__________________________________________ Father_____________________________________________
Campers Health History (Check all that apply to your child):
_____Ear Infections                                       ______Hay Fever                     ______Penicillin allergy
_____Convulsions                                         _______Ivy Poisonings                ______Asthma
_____Other Drug Allergies                                _______Allergy to Insect Stings ______Diabetes
_____Other (please explain):__________________________________________________________________

**Please attach a copy of your child’s shot record.
List any serious illness or injury you child has had during the past 12 months:___________________________
_________________________________________________________________________________________
Family Physician: Name______________________________________________Phone___________________
Date of child’s last physical examination _______________________________________________________
List any medication your child must take while at day camp______________________________________
**WE WILL NOT GIVE YOUR CHILD ANY MEDICATION WITHOUT SIGNED, ORIGINAL
NOTIFICATION FROM HIS/HER DOCTOR (copies or faxes are not acceptable).
Camp activities you wish encouraged___________________________________________________________
Activities you wish discouraged________________________________________________________________
*********************************************************************************************************************************************
AUTHORIZATION
This health record is true and correct to the best of my knowledge, and the person herein described has my permission to engage in all
prescribed camp activities, except as noted above. In the event that I can not be reached in an EMERGENCY, I give permission to
transport my child to ________________________________Hospital and for the attending physician to secure proper treatment. If I
cannot be reached in an EMERGENCY, you may contact the following person who is authorized by me to make medical decisions on
behalf of ___________________________(child’s name)

____________________________________              ________________________________ ___________________
Authorized Person                                 Relationship                                Phone Number


Parent/Guardian Signature________________________________________________Date________________________

________(please initial) I have received my “Camp Adventure Brochure” which explains this program in detail.
                                             CAMP ADVENTURE
                                POLICY & BEHAVIOR ACKNOWLEDGEMENT FORM


As camp is beginning, please take the time to review basic cooperative and courteous behavior with your child. If our staff
should encounter behavioral difficulties with your child, you will be notified. Depending on the severity and number of
occurrences, our staff will make the appropriate determination on a course of action to be taken. This may range from
removing a child from a specified activity to suspension from the program. Basic acceptable behavior includes, but is not
limited to:

1.   Use appropriate language at all times!                                2.    No Fighting – verbal or physical
3.   Show respect to all – campers and staff                               4.    Obey all Safety Rules
5.   Respect the property of others                                        6.    Stay in assigned areas
7.   Remain with group or buddy at all times, NEVER wander alone


Discipline course of actions:

1.    Omission from Activities
2.    Discipline referral (report)
3.    Camp suspension

Note: Any fighting or violent behavior will result in immediate camp suspension.


*BUS BEHAVIOR*

1.    Stay seated
2.    Stay away from windows
3.    No food or drink
4.    Keep hands and feet to yourself
5.    Use appropriate language and voice volume
6.    Do not throw anything


Note: If your child is suspended from the bus for behavior problems, you must provide transportation to and from camp
during suspension.

Please understand that no refunds or credits will be given for discipline problems that result in camp suspension.


I have reviewed the behavior guidelines with my child/children and fully understand the outcomes of severe or continuous
disciplinary problems.


___________________________________________                                ___________________________
Parent/Guardian Signature                                                   Date
              Camp Adventure Camper Questionnaire
Parents/Guardians, please have your child complete this form with their own answers. You may
help them complete this form, but please let them answer honestly so that we can better serve
your child at camp. Thank You!!!


Please circle your answer or fill in the blank.

1. Have you ever gone to any camp before?                  YES          NO

      If “YES”, what kind of camp was it? ______________________________

2. What do you want to do at Camp Adventure? __________________________

_____________________________________________________________

_____________________________________________________________

3. Something new I would like to try is ________________________________

_____________________________________________________________

4. I get bored when ______________________________________________

_____________________________________________________________

5. Some things I would like my counselors to know about me is _______________

_____________________________________________________________

_____________________________________________________________

6. I am comfortable in the water: YES       NO
Please explain:
_____________________________________________________________

_____________________________________________________________

				
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