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) __________________________________________________________________
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: _______________________________________________________________
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)
|Diphtheria||Mumps||Varicella (Chicken Pox)|
Operations, serious injuries or illnesses and dates: _______________________________________
Penicillin or other drug reactions: ____________________________________________________
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: ____________________________________________________
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
Half day: 4-6 year old
Full day: 7-13 years old
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:
- Bible (if you do not have one, we can provide)
- Water Bottle
- Sneakers & Socks
- Hat (optional)
- Sun glasses (optional)
Full Day only:
- Swim suit (girls need a one piece, no bikinis)
- Bag for swim suit & Towel
- If you need certain equipment for athletics like cleats, mouth piece, sports glasses, swim goggles, nose plug, etc…
Things NOT to bring to camp:
- Glass bottles
- Sandals/Flip Flops/ high heels, or open toed shoes
- Electronics: I-Pod, Gaming device, I-Pads, cell phone (only if it is kept in ones bag)
- Jewelry: too easy to loose, get stolen, or damaged
- 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)
- 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.