Summer Day Camp Enrollment Form

* - required fields (if a field does not apply, enter N/A)

Name: * Male * Female *

Address: * City: * State: * Zip: *

Home Phone: * Birth Date: * Age as of June 1st, 2010: *

Name of Current School: * Grade in Sept, 2010: *

Week	Date	2 Days	3 Days	4-5 Days	Not Selected	Extended hour $7/day
Week 1	7/6-7/9	$110 $145 $150 Not Selected
Week 2	7/12-7/16	$110 $145 $190 Not Selected
Week 3	7/19-7/23	$110 $145 $190 Not Selected
Week 4	7/26-7/30	$110 $145 $190 Not Selected
Week 5	8/2-8/6	$110 $145 $190 Not Selected
Week 6	8/9-8/13	$110 $145 $190 Not Selected
Week 7	8/16-8/20	$110 $145 $190 Not Selected
Week 8	8/23-8/27	$110 $145 $190 Not Selected
Total: * + $10.00 (T-shirt fee) = Grand Total: *

 

Approximate drop off time: * a.m.     Approximate pick up time: * p.m.

A Deposit of $100.00/week must be sent with the application in order to save a spot for your children.

$100 x * = * (You will be able to pay this online after you submit your application.)

TShirt size: * Youth S (6-8) Youth M (10-12) Youth L (14-16) Adult S Adult M Adult L

Father's Name: * Cell: *

Father's Work Address: * Work Phone: *

Mother's Name: * Cell: *

Mother's Work Address: * Work Phone: *

Father's Occupation: * Mother's Occupation: *

E-mail Address: * - a copy of this form will be sent to this email

Child lives with: * Mother Father Both Guardian

Emergency Contact: *
Relationship to Child: * Phone: *

Family Doctor: * Phone: *

Any medications to be taken at camp:
*

Are you able to volunteer on Wednesdays for our field trips: * Yes No

In the event I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected by the camp director to secure proper treatment for my child as named above. I further accept the responsibility that my child is physically and emotionally able to participate in camp activities. I have read and fully agree with all the terms of registration as stated in the CAMP AGREEMENT form.

I further agree to allow my child to be used in any promotional photos. * Yes No

Date: * Enter Name (same as your signature): *

Member of Homenetmen Glendale "Ararat" Chapter: * Yes No

I learned about Camp from: * Friend Website Camp Flyer School Other

MEDICAL PERMIT

As the parent/legal guardian, I hereby give consent to HOMENETMEN GLENDALE "ARARAT" CHAPTER to provide all emergency dental or medical care prescribed by duly licensed physician (M.D.) or dentist (D.D.S.) for * in case of illness or accident when neither parent can be located.

The medical services are to be performed by * M.D. (Address and telephone) * Or by physician of his/her choice, or in his/her absence, by a licensed medical doctor.

MEDICAL INFORMATION

Is your child...?

1. Allergic to medication? * Yes No
   • If yes, please name the medications:
     
2. Allergic to anything else? * Yes No
   • If yes, please describe:
     
3. Taking any medication? * Yes No
   • If yes, please name them all:
     
4. Any chronicle illness? * Yes No
   • If yes, please name the illness:
     

Date: * Enter Name (same as your signature): *

PARENT CONSENT

Child's Name: * I.D. # *

I, * * Mother Father Guardian of * agree and authorize to the following:

Tylenol Consent:
Administer Tylenol: * Yes No

Field Trips & In-House Educational Programs:

I, * authorize my child to participate in any field trips & in-house educational programs organized by Homenetmen Glendale "Ararat" Chapter. * Yes No

Photographs & Videos:

I authorize Ararat to photograph and video tape my child during his/her camp activities and release these photos and videos to public broadcasting networks or any educational organization for Summer Day Camp introduction purposes. * Yes No

Pick Up:

The following persons are authorized to pick up my child from Summer Day Camp:

1. Name: * Relationship: * Phone: *
2. Name: Relationship: Phone:
3. Name: Relationship: Phone:

Water Play:

I authorize my child to participate in supervised water play activities. * Yes No

DAY CAMP TERMS & CONDITIONS

REGISTRATION:

Camp registration is considered on an individual child basis only. Each child in the family must have his/her own separate registration form and each form is processed in the order in which it is received together with the appropriate payment or deposit. Incomplete forms will delay registration.

If there is no space available at the time the registration form is received, the parent will be notified and the child is automatically placed on the waiting list. (Waiting list procedure explained below).

To reserve space: complete and sign one registration form for each child along with a deposit of $100.00 per week.

Your child will not be allowed to attend the Day Camp if your fees have not been paid - NO EXCEPTION

DISCOUNTS:

There will be 10% discount for 2nd child enrolled.

HOURS OF OPERATION:

Summer Day Camp program hours are 9:00 a.m. to 3:00 p.m. Early drop off (7:30 a.m.) & late pick up (6:00 p.m.) is available for $7.00 per day (Snacks included). Free extended day care is available from 8:30 to 9:00 a.m. & from 3:00 to 3:30p.m.

DROP OFF AND PICK UP:

Drive in to our back parking lot and park your car (the gate will be open at all times). Walk your child/ren from the Foyer (banquet hall entrance) door. This year we will be gathering in the Foyer (banquet hall entrance). Make sure to sign in your child at the desk next to the entrance door. Please allow adequate time for the sign in process. As for the pick up, if you are picking your child from 2:30 to 4:00 you can pick them up from the Foyer (banquet hall entrance). If picking up your child after 4:00 p.m. you must pick them up and sign them out from our gathering room or the second floor. After 4:00 only the main front entrance on San Fernando will be open.

CANCELLATION:

There will be a $50.00 cancellation fee.

WAITING LIST:

Due to limited capacity it is advisable to register early. Ararat will maintain a waiting list for each week when the camp fills up. Applicants are automatically placed on the waiting list in the order in which their registration form is received, and the parents are so notified. We cannot add your child's name to the waiting list without a completed registration form and $100.00 deposit for the week. The child will remain on the waiting list until a space opens.

ACTIVITIES:

Field trips, swimming, outdoor, and recreational activities are an important part of the day camp program and are included as part of the total camp fee. Any physical activity, of course, has risks, but Ararat believes that with proper supervision, the benefits derived far outweigh these risks. If you do not wish your child to participate in any given activity, we need a written statement that you do not want your child to participate in that specific activity.

LOST AND FOUND:

Your child should bring a clean change of clothing to camp each day in his/her backpack. Everything brought to Ararat should be marked with the child's name. Although the staff will try to prevent lost articles, the child should learn to be responsible for his/her own clothing. After the completion of last week of the camp articles left in camp will be sent to Armenia.

SHIRTS:

Kids must wear the Summer Day Camp t-shirt on Wednesdays, our field trip days to be identifiable as part of Ararat Kids. Each T-shirt is $10.00. By the first Wednesday (Field Trip Day) of your child’s first week of attendance the $10.00 must be paid.

ABSENCES:

The office would greatly appreciate a call if your child is going to be absent, especially on days when field trips are planned. There is an answering machine to take your call. The phone number is 323-256-2564. NO MAKEUP DAYS OR CREDITS WILL BE GIVEN FOR ANY REASON.

ACCIDENTS:

In the event a child is hurt at Ararat or on a field trip and needs emergency treatment, the staff will try to reach the child's parents, the emergency contact, or the family doctor. Ararat 's accident insurance covers, up to our policy limits, any injuries received at camp to the extent that they are not covered by your health and/or accident insurance.

IMPORTANT NOTES:

Snacks and lunch will be provided by Ararat Day Camp.

Water shoes/water socks; swimsuit, towel, hat & sun block are required for water activity days & pool days. No water socks, no water activity, no exceptions.

Pictures taken during activities will be displayed on our website & could be purchased through dot photo.

No video games or electronic devices are allowed.

Fridays are share days; your child can bring one toy to share with others.