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Camper Application

2016 Camper Registration Form

Mail registration, health form, and check to:

Vineyard Church Summer’s Best of Irondequoit

2150 Portland Avenue

Rochester, New York 14617

(Make checks out to Vineyard Church of Irondequoit)

Camp is August 8th to the 12th

For a free camp t-shirt please register by July 18th

Attending (please circle)          (4-6yrs/old) Half Day      (7-13yrs/old) Full Day

Camper’s Name:                                                         Nickname (if used):____________________ _                                       

Home Phone: (       )          -________   Home Address: ___________________________________

(town/zip code) __________________________________________________________________

Email: __________________________________________________________________________

Male or  Female (circle one)

Present Age: ________           Date of Birth: ______________

Height: ___________             Weight: ___________

T-Shirt Size: Youth XS, S, M, L, XL, Adult: XS, S, M, L, XL

# of previous years at Summer’s Best of Irondequoit: __________     Roman or Galatian (circle one)

Parent or Guardians’ Name(s):_________________________________________________________

Is camper living with both parents? Yes or No (circle one)    If not, with whom? _________________

Home church (if applicable): _________________________________________________________

Briefly describe what you hope your child will get out of camp:______________________________

_________________________________________________________________________________

Emergency Contacts (please provide at least two names)

Primary Parent/ Guardian’s Name: __________________ Relationship to camper: ___________

Phone Number: (       )         –__________                  Alternate number: (       )         –__________

 

Second Parent or Guardian’s Name: _________________ Relationship to camper: ___________

Phone Number: (       )         –__________                  Alternate number: (       )         –__________

Volunteer Opportunity (check box if interested)

? I am interested in helping out in the Camp Office

? I am interested in being a driver for SB2W’s

? I am interested in being the Camp Nurse

 

 

 

Summer’s Best of Irondequoit: Camper Application page 2.

 

How did you hear about us????

? Been a camper in the past

? Saw it advertised in the community

? Referred by a friend or family member (If so, who? _____________________________)

? Other ____________________________________

 

To be completed by parent/guardian:

 

I, __________________________________________________________(Parent/Guardian’s name)

 

give permission for  _________________________________________________(Camper’s name)

 

to participate actively in the total program, except as follows: _____________________________

 

__________________________________________________________________________________

 

I, ___________________________________________________________(Parent/Guardian’ name)

 

hereby grant permission for__________________________________________(Camper’s name) to

 

appear in photos taken by camp officials that may or may not be posted to the camp websites

(no names will be used).

 

I, _________________________________________________________ (Parent/Guardian’s name) give Summer’s Best of Irondequoit permission to apply sunscreen on, ___________________________________________________________________(Camper’s name).

That the camp provides:   YES        NO    (please circle one)

Summer’s Best of Irondequoit provides:  Wegmans Sports Sunscreen SPF30

I, __________________________________________________________(Parent/guardian’s name) give Summer’s Best of Irondequoit permission to transport my child,________________________ _________________________________ (Camper’s name) to and from Swimming at East Irondequoit High School, Canoeing at the Irondequoit Bay off of Empire Blvd., and Archery at J.V. Fishing (1449 Norton St.).

Does your child require a booster seat:  YES         NO   (please circle one)

If YES, can u provide the booster seat:  YES        NO   (please circle one)

 

 

Summer’s Best of Irondequoit: Camper Application page 3.

 

Per New York State Law, a physician’s signed permission must be on file for all medications to be given at camp (including over-the-counter medications).

 

Medication to be administered at camp:________________________________________________

 

Dose:  ___________________________________ Time:  ___________________________________

 

Physician’s signature:  _______________________________________________________________

 

Date:  __________________________

 

A doctor’s examination and signature are not required on this form except for the medication permission at the bottom.

Camper Name: _________________________________________________________________

 

Medical Insurance (carrier and policy #): ______________________   #____________________

 

Physician’s Name:__________________________   Physician’s Phone: (        )_____-_________

Immunizations (give date of most recent vaccine, “up-to-date” not acceptable)

Tetanus Measles Polio
Diphtheria Mumps Varicella (Chicken Pox)
Pertussis Rubella Haemophilus (Hib)
Hepatitis B Other  

 

Operations, serious injuries or illnesses and dates: _______________________________________

Penicillin or other drug reactions: ____________________________________________________

Allergies: _______________________________________________________________________

Prescription medications: __________________________________________________________

List existing medical conditions (such as ADD, nosebleeds, car sickness, headaches, etc.): ________________________________________________________________________________

Describe any additional physical or emotional needs: _____________________________________

________________________________________________________________________________

I approve the application and conditions above.  I have written any necessary and pertinent information concerning our family and our child.  In case of emergency, I understand that every effort will be made to contact me.  If I cannot be reached, I hereby give permission to the physician selected by the Camp Director to hospitalize and secure proper treatment (including injections and surgery) for my child.

Parent/Guardian Signature: ____________________________________________________

Date: __________________

 

Health form INCLUDED.  Application must be  accompanied by complete medical release  form to reserve a spot for your child.
Summer’s Best of Irondequoit: Camper Application page 4.

 

SUMMER’S BEST of Irondequoit 2016

Camp Details & Information

 

PLACE: Vineyard Church of Irondequoit, 2150 Portland Ave. 14617

 

DATES: August 8th to August 12th, 2016

 

COST:     Half day: $50 for one week

Full day: $105 first child, 10% discount for more than 1 child

($190 for two children, $280 for three children)

T-shirt included if you register by July 18th

AGES:

 

Half day: 4-6 year old

Full day: 7-13 years old

 

TIME:

Half day 9:00 am to 12:30 pm

Full day 9:00 am to 4:30 pm

 

Refund Deadline: July 18th, 2016

Financial Aid: Applications available upon request

Activities: Track and field, swimming, archery, football, soccer, volleyball, kickball, craft, Bible study, basketball, canoeing, and much more!

 

  • All counselors are trained and experienced.
  • If you would like to volunteer some time in the camp office, driver, etc…please contact the camp director.

 

 

For more information, please contact the camp director:

Bill Lydon: (585) 750-2749

Summer’s Best of Irondequoit: Camper Application page 5.

SBTW is under Monroe County Department of Health permit.

Records of inspections can be obtained in the camp office.

 

Rights and Responsibilities

 

The regulatory program of the New York State Department of Health places specific responsibilities on camp operators, and on local health departments that enforce department regulations. Following is a summary of rights and responsibilities:

 

Rights of Parents and Guardians

  • To be informed by the camp director, or his or her designee, of any incident involving your child, including serious injury, illness or abuse.
  • To review inspection and investigation reports for a camp, which are maintained by the local health department issuing the camp permit to operate (present and past reports are available).
  • To review the required written camp plans. These are on file at both the camp and the health department issuing the permit to operate.

 

Responsibilities of the Camp Operator

  • To inform you and the local health department if your child is involved in any serious injury, illness or abuse incident.
  • To screen the background and qualifications of all staff.
  • To train staff about their duties.
  • To provide supervision for all campers during hours of operation for day camps.
  • To maintain all camp physical facilities in a safe and sanitary condition.
  • To provide safe and wholesome meals.
  • To have and follow required written plans for camp safety, health and fire safety.
  • To notify the parent or guardian, with the enrollment application or enrollment contract, that:
  • the camp must have a permit to operate from the New York State Department of Health or the designated permit-issuing official;
  • the camp is required to be inspected twice yearly; and
  • the inspection reports and required plans are filed (address of state, county or city health department) and available for their review.

 

Responsibilities of Local Health Departments

  • To review and approve the required written camp plans for compliance.
  • To inspect camps to assure that: (1) all physical facilities are properly operated and maintained; and (2) adequate supervision exists to provide a healthy and safe environment in accordance with the New York State Sanitary Code.
  • To issue a permit to operate when the required plans and inspection results are satisfactory.
  • To investigate reports of serious incidents of injury, illness and all allegations of abuse or maltreatment.
  • When requested, to provide parents or guardians of prospective campers an opportunity to review inspection reports and required plans.

 

For further information about health laws relating to summer camps, call the Monroe County Department of Health at (585) 247-6065.

 

Summer’s Best of Irondequoit: Camper Application page 6.

 

Things to bring to camp:

All campers:

  1. Bible (if you do not have one, we can provide)
  2. Lunch
  3. Water Bottle
  4. Sunscreen
  5. Sneakers & Socks
  6. Hat (optional)
  7. Sun glasses (optional)

 Full Day only:

  1. Swim suit (girls need a one piece, no bikinis)
  2. Towel
  3. Bag for swim suit & Towel
  4. If you need certain equipment for athletics like cleats, mouth piece, sports glasses, swim goggles, nose plug, etc…

 

Things NOT to bring to camp:

  1. Glass bottles
  2. Sandals/Flip Flops/ high heels, or open toed shoes
  3. Electronics: I-Pod, Gaming device, I-Pads, cell phone (only if it is kept in ones bag)
  4. Jewelry: too easy to loose, get stolen, or damaged
  5. Inappropriate clothing: Shirts with swearing, rude remarks, or violent pictures or tops that are low cut, expose the belly, or have spaghetti straps…tank tops and sleeveless t’s are ok, no short shorts…must be finger tip length ( we do understand that clothes are sold in certain lengths)
  6. Weapons, tobacco products, or alcohol

 

If you have any questions regarding what to bring or not to bring you can contact,

Bill Lydon @ #750-2749.