Summer of Discovery 2009 Registration Form
Summer of Discovery 2009 (entering grades 1-5) Select your school . . .
Registration Information
Child’s Name: ___________________________________ Address: _______________________________________ Home phone: ________________ Child’s age: _________ School: ____________________ Grade Sept. 2009: ____ Please list any special limitations or health information we should know about your child, including any infectious diseases; special medications, including dietary restrictions and allergies. ___________________________________ Parents/Guardians: Name: _____________________ Relationship: ________ Address: _______________________________________ Work phone: ________________ Cell: _______________ Name: _____________________ Relationship: ________ Address: _______________________________________ Work phone: ________________ Cell: _______________ Emergency Contacts: Name: _____________________ Phone: _____________ Name: _____________________ Phone: _____________ Transportation In order to keep our children safe, we must know how they will leave the program. If a child has permission to walk home, or take public transportation, your signature is required. Children are released only to parents and/or emergency contacts listed here. My child will be picked up. My child will walk home _________________________ Parent Signature/Date Financial Aid Limited financial aid will be available at each school, and will be awarded on a first-come, first-served basis. You will not be considered for financial aid without 2008 tax paperwork. Enclosed is a COPY of my 2008 1040 for financial aid. Payment A one week deposit is required with your application for the Summer of Discovery Camp A one-time $25 registration fee per child is due for the summer programs. It must be included with this form and is non-refundable. Make checks payable to City of Malden. A confirmation will be sent for registrations received by June 5. If we do not receive payment your space will be released and you will be placed on a waiting list. I agree that I am responsible for the programs selected here. I agree that my child will attend these classes and I will pay for them. ____________________________ Parent Signature/Date
Beebe
Salemwood
July 6 July 27
Select your week . . .
June 22* July 13 June 29** July 20
Select your days . . . 2 day option (Tuesday and Thursday) 3 day option (Monday, Wednesday, Friday) 5 day option (Monday through Friday)
Select your times . . .
8:00 am to 4:00 pm ($36 per day) 8:00 am to 12:00 12:00 to 4:00 - $20/day each 7:00 to 8:00 (minimum of 5 students/day) ($8/day) * Program starts Wednesday, June 24. Cost prorated. ** Cost prorated week of June 29. No program July 3.
There is a 15% sibling discount for siblings who attend the same program.
Sports Camps Co-Ed Baseball Tennis Gymnastics Girls Basketball Songwriting Boys Lacrosse Boys Basketball Girls Lacrosse Field Hockey
June 22 June 29 July 6 July 6 July 13 July 13 July 13 July 20 July 28
$100 $ 80 $100 $100 $ 90 $ 80 $100 $ 80 $ 80
Channel Surfing (entering grades 6-8) Select your school . . .
Beebe
Salemwood
July 13
Select your weeks . . . (Monday to Thursday) *
June 29 July 6 July 20 July 27
* Students must attend a minimum of 2 weeks Please return your registration form to PCSM by June 5. Mail completed registration forms to PCSM at 238 Highland Avenue
Summer of Discovery 2009 Consent Form
Medical Treatment
I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I authorize PCSM or its contracted agency to transport my child to the nearest hospital or medical facility and to secure for my child the necessary medical treatment. I authorize trained employees of PCSM or its contracted agency to administer first aid and/or CPR if necessary. Yes No Child’s Name: _____________________________ Physician Name: ____________________________ Phone Number: ___________________ Policy #: ________________________ Physician Address: ____________________________________ Insurance Provider: ___________________________________
Parent/Guardian Signature: ___________________________________ Date: ____________________
Photographs
Pictures, photographs, and video are taken of activities from time to time for the purposes of school-based newsletters, newspaper articles, or other publications. Any children pictured in these publications will not be identified by name. Please sign below your preference for your child’s participation. Yes No
Parent/Guardian Signature: ___________________________________ Date: ____________________ Field Trips:
Field trips may be scheduled from time to time. If we plan a field trip, it will be in advance, and we will send home a letter with your child describing the trip. We will always have adequate supervision, and follow established safety guidelines on all trips. A separate permission slip will be sent out for any and all field trips. Parent/Guardian Signature: ___________________________________ Date: ____________________
Behavior Program:
We ask the cooperation of family members at home to reinforce behavior, and let students know they must conduct themselves properly throughout the program. We want to provide a safe environment that promotes appropriate social interactions. In order to do that we have developed the following behavior rules. 1. For the first disruptive incident a verbal warning to the student and his/her parents/guardians will be notified. 2. Second disruptive incident will result in a mandatory one day suspension from the program. 3. The third disruptive incident will result in a suspension from the program for a designated number of days (at the discretion of administration) 4. If there is a fourth disruptive incident, the student will be removed from the program with parent/guardian notification. A decision will be made as to whether the child can return for subsequent sessions. Immediate removal from the program will occur if a student exhibits physical behavior that risks the safety of his/her self or another student or staff member. I agree with these guidelines Parent/Guardian Signature: ___________________________________ Date: ____________________
Student Pick Up
Departure time is 12:00 or 4:00 pm. Please inform the program staff in writing ahead of time when your child has to leave early (for example, for a doctor’s appointment) or will be absent. Students must be picked up on time. Our policy follows: After 5 minutes you will be charged $1.00 for each minute you are late. After 10 minutes you will be charged $2.00 for each minute you are late. After 10 minutes, emergency contacts will be notified. If after 30 minutes the student is not picked up the Department of Social Services will be contacted. Late fees must be paid before your child can return. Employees will use the school clocks for reference. In addition to being picked up on time, children will only be released to people listed on your registration form. If you wish to add someone to your list, contact PCSM. Individuals picking up a child must present a photo ID. With written parental consent, children may walk home from the program. I agree with these guidelines Parent/Guardian Signature: ___________________________________ Date: ____________________