ABC Care Summer Camp Registration 2020

ABC Care Camp Registration

Summer 2021
Camper's Information
Which Camp will your child be attending? *

DeerPark Adventure Camp Eldersburg Adventure Camp at Piney Run Park
Child's Name *
Birth Date *

Month Day Year
Date
Gender *

Male Female
Address *

Street Address

Street Address Line 2

City State

Zip Code
Grade entering in Fall (2021/22) If your child is in 9th grade or above, they will automatically be enrolled in our Counselor In Training (CIT) Program at a reduced rate. *
School child will attend in the Fall *
If other, Please tell us which school your child attends:
Are you a School Year 2020-2021 ABC Care Family? *
If yes, please indicate ABC Center your child attends:
Did your child attend camp last year? *

Yes No
Name of Sibling(s) *Please note, you MUST complete a separate registration for each child.
How did you hear about us? *
If other or referral, please list name or how you heard about us:

Camp Gear
Each camper will receive one FREE t-shirt. T-Shirt Size *
If you would like to purchase an *additional* T-shirt ($10), please mark which size you will need.

Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult Extra Large
ABC Care has additional camp gear available, please mark your choice if you would like to purchase.

ABC Care Aluminum Water Bottle ($6)

Parent/Guardian Information
Parent/Guardian *

First Name Last Name
Relationship to Child *
Same Address as Child?

Yes
Address *

Street Address

Street Address Line 2

City State

Zip Code
E-mail *
Cell Phone *
Home Phone
Work Phone
Additional Parent/Guardian ABC is authorized to discuss this account with:

First Name Last Name
Relationship to child?
Phone
E-mail
example@example.com
In SmartCare, our attendance and billing program, the first parent/guardian listed is the account holder and considered the primary parent. That parent has access to all areas of SmartCare including, but not limited to, billing, attendance, schedule, etc. The second parent/guardian listed can have access to the attendance portion of the app, can share billing information with the primary parent, and/or can have their own billing account information for cases where parents/guardians are splitting the cost and payments. Please choose the role of the second parent/guardian listed below:

Only needs access to the attendance portion of the app. Does NOT need access to any billing/payment information Will need attendance portion of the app AND access to the same billing/account information as the primary parent Will need attendance portion of the app AND their OWN SEPARATE BILLING/PAYMENT account for their portion of the bill
If parents are having separate billing accounts, please list the percentage of billing to go to primary parent ___ and percentage of billing to go to secondary parent ___
Signature: (hold down left pointer button on mouse to sign) *

Clear
Date Signed *

Month Day Year

Emergency Contacts/Authorized Pickup

Please list the name of at least one person, preferably two, who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the camp/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.
Emergency Contact #1
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Primary Phone Number *
Secondary Phone Number
Relationship to Child *
Emergency Contact #2
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Primary Phone Number *
Secondary Phone Number
Relationship to Child *
In EMERGENCIES requiring immediate medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. Your signature authorizes the responsible person at the camp to have your child transported to that hospital. Please sign below. (hold down left pointer button on mouse to sign) *

Clear
Date *

Month Day Year
Date

PAYMENT INFORMATION
Once you sign this agreement, you will be sent an email within 1 week with instructions on how to log in or create an account in SmartCare, our billing program. You must fill out your billing information and pay your security deposit as well as registration fee within 3 days of receiving the email or your registration will be cancelled. This can be paid either in SmartCare or by mailing or dropping off a check to our main office, or to one of our 11 center Site Directors. If you have any questions or concerns, you can contact our main office at 410-751-3700.
Once registration fees and security deposit have been paid, how would you like the balance of your tuition paid? (Balance of June fees due 5/31/21, July fees due 6/18/21, August fees due 7/16/21. *

Automatic ACH withdrawal Automatic credit card withdrawal (2.85% processing fee) Personal check Self process thru SmartCare
By signing this registration agreement on behalf of my child, I acknowledge I am financially responsible for the weeks indicated on the registration form. In case of voluntary withdrawal, absenteeism, deduction of weeks or if my child is removed from camps, I understand there will be no refund of camp fees or credit applied to my account. I agree to complete any additional paperwork (medical forms) and submit two weeks prior to start date of the camp week. I have read or will read the 2021 Summer Camp Parent Manual in its entirety and will abide by the requirements and policies as stated.
Signature: (hold down left pointer button on mouse to sign) *
Date Signed *

Month Day Year

YOUTH CAMP HEALTH HISTORY
Child's Name *

First Name Last Name
Child's Current Address *

Street Address

Street Address Line 2

City State

Zip Code
EMERGENCY CONTACT INFORMATION:
Emergency Contact: (Parent or Legal Guardian) *

First Name Last Name
Primary Phone Number *
Emergency Contact: (Other than Parent Above) *

First Name Last Name
Primary Phone Number *
Primary Care Physician (or other provider of medical care): *

First Name Last Name
Primary Care Physician Phone Number *
HEALTH INFORMATION:
Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware? *

No Yes
If yes, please explain, otherwise mark N/A: *
Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child's camp experience is positive? *

No Yes
If yes, please explain, otherwise mark N/A: *
IMMUNIZATION INFORMATION:
For campers who currently reside within the United States, a United States territory, or the District of Columbia: Does the camper have any immunization exemptions because of a parental or guardian objection or medical contraindication? *

No Yes
If yes, LIST, otherwise mark N/A: *
For campers who reside outside the United States, a United States territory, or the District of Columbia: Attach record of vaccination or immunity on Department form MDH-896

Will your child need to have medication administered while at camp? *

Yes No
**If your child will be needing to take medication while at camp, you will need to print the Medication Administration Authorization Form and/or the Asthma Action Plan and Administration Form, fill it out completely and get it back to us a minimum of 2 weeks prior to camp.
Medication Administration Authorization Form
**If your child uses asthma medication, please print this form, fill it out and return it to us no later than two weeks prior to the beginning of camp. See attached.
Asthma Action Plan & Medication Administration Authorization Form

SUMMER CAMP POLICY MANUAL ACKNOWLEDGEMENT FORM
2021 Summer Camp Policy Manual
I have read the ABC Care, Inc. Summer Camp Policy Manual and agree to abide by the requirements and policies as set forth by ABC Care, Inc. Please sign below. (hold down left pointer button on mouse to sign) *

Clear
Date *

Month Day Year
Date

ACTIVITIES PERMISSION
I give permission for my child to participate in all activities, including: *

Paddle Boats (Minimum of 1 staff per paddle boat) Swimming in a pool (zero entry and lifeguard on duty) Bicycle riding (DeerPark Camp only, parent provides helmet) None of the Above
Child's Name *
By signing below, you acknowledge that you have given permission for your child to participate in the activities selected. (hold down left pointer button on mouse to sign) *

Clear
Date *

Month Day Year
Date

SUNSCREEN PERMISSION
Child's Name *

First Name Last Name
It is the policy of ABC Care, Inc. that all children need sunscreen for their protection from the sun's harmful rays.
1. Parents need to apply sunscreen to their child(ren) before arriving at camp.
2. Parents need to supply sunscreen for their child(ren). Sunscreen supplied should be easily used by camper with little assistance. Campers should be able to apply their own sunscreen throughout the day.
3. Staff will supervise the application of sunscreen throughout the day and record the usage. Reapplication of the sunscreen should be according to the directions written on the container.
4. ABC Care staff may assist in the application of sunscreen on campers if necessary. Campers are not allowed to assist other campers in applying sunscreen .
SUNSCREEN NAME *
SPF *
Should my child need sunscreen in the event it ran out or it was forgotten, I give ABC Care, Inc. permission to apply camp generic sunscreen to my child. *

No Yes
Parent's Signature: (hold down left pointer button on mouse to sign) *

Clear
Date *

Month Day Year
Date

TRANSPORTATION AUTHORIZATION
I give ABC Care, Inc. permission to transport my child, listed below, by certified school bus service and/or ABC Care, Inc. van to and from all field trips, and between all ABC Care, Inc. summer camps.

Your signature on this blanket permission slip allows your child to attend scheduled field trips and/or ABC Care, Inc. summer camp locations for the weeks registered.

In case of emergency such as a natural disaster or national emergency, your signature on this blanket permission slip allows your child/ren to be transported by a Maryland certified bus company or ABC Care, Inc. staffer vehicle to the nearest disaster relief shelter. ABC Care, Inc. will notify parents/guardians of children’s emergency location via telephone call. The emergency telephone number (s) we use to contact parents/guardians are listed on the child’s emergency form.

I understand that all necessary precautions will be taken by ABC Care, Inc. for the safety of my child.

Reminder: Children are required to wear their camp T-shirt on field trip days. Also, ensure your child has a disposable lunch in an insulated bag with two box drinks and that he/she wears appropriate clothing as well as appropriate shoes. Thank you.
Child's Name *

First Name Last Name
Parent Signature: (hold down left pointer button on mouse to sign) *

Clear
Date *

Month Day Year
Date

PUBLICITY/PHOTOGRAPHY/VIDEO RECORDING RELEASE
From time to time our program may involve photographing, video recording, interviewing by an outside source, and other publicity pictures of the children in our program.

It is required by our licensing agent, Maryland Department of Health and Mental Hygiene, that parents/guardians grant permission for this type of publicity.
My child may be photographed, video recorded, or interviewed for: *

Yes No
Child's Name *

First Name Last Name
Parent's Signature: (hold down left pointer button on mouse to sign) *

Clear
Date *

Month Day Year
Date

BEHAVIORAL MANAGEMENT PLAN

PROCEDURES REGARDING INAPPROPRIATE BEHAVIOR
A child who is involved in any type of behavior that is determined by the Camp Director and Manager of ABC Care, Inc. to be conduct unacceptable for a child attending an ABC Care Summer Camp Program can be suspended or expelled. The Senior Manager or Executive Director has the authority to determine the length of the suspension or expulsion, which can range from one (1) to five (5) days.

ABC Care Inc. reserves the right to employ the following procedures in dealing with instances of inappropriate behavior:
1. The Camp Director of the camp may confiscate inappropriate and/or objectionable materials and/or objects that may be used for inappropriate behavior.
2. The Camp Director of the camp, with the Senior Manager’s guidance, reserves the right to determine the degree of punishment (i.e. Incident Reports, suspension, expulsion)
3. The Executive Director or Senior Manager has the right to request full payment for total replacement and/or monetary reimbursement for repairs and/or replacement of broken/destroyed objects resulting from a deliberate or accidental breakage. This includes and is not limited to center equipment, school items, and children/staff personal belongings.
4. Field trips are a privilege. The Camp Director of the camp reserves the right to withhold a child from attending a field trip.
5. The Camp Director of the camp reserves the right to request that a child’s parent accompany him/her while attending a field trip.
6. The Executive Director or Senior Manager reserves the right to require counseling and/or psychological testing.
OFFENSES

The following lists are examples of SOME of the offenses for which a child may receive an Incident Report, suspension, or expulsion, depending on the circumstances and severity surrounding the offense.

INCIDENT REPORTS
1. Leaving the designated area that ABC Care is utilizing at that time.
2. Throwing rocks or sticks
3. Failure to refrain from hurting another (pinching, pushing, punching, biting, kicking, etc...)
4. Using vulgar language, verbally or in written form
5. Showing disrespect to another person (child or staff member)
6. Improper use of equipment, materials, or furniture
SUSPENSIONS WHICH MAY RESULT IN EXPULSION
1. Failure of parent(s) to attend a parent conference or adhere to its recommendations
2. Theft/Robbery
3. Use or possession of tobacco or firearms
4. Arson/lighting matches
5. Assault and battery of a staff member
6. Violent behavior which creates a substantial danger to persons or property
7. Possession of a real or look-a-like weapon
8. Destruction and vandalism of school or personal property
9. Fire alarm misuse
10. Harassment
11. Insubordination (disobeying a directive from a Camp Director or camp counselor)
12. Gambling for money
13. Lack of required immunizations or health inventories
14. Sexual activity or indecent exposure
I have read and understand the behavioral management plan of ABC Care, Inc. and the procedures regarding inappropriate behavior and will agree to their implementation. Parent's Signature: (hold down left pointer button on mouse to sign) *

Clear
Date *

Month Day Year
Date
Should be Empty:

ABC Care Camp Registration

Camper's Information

Camp Gear

Parent/Guardian Information

Emergency Contacts/Authorized Pickup

Emergency Contact #1

Emergency Contact #2

Choose Your Camp

PAYMENT INFORMATION

YOUTH CAMP HEALTH HISTORY

SUMMER CAMP POLICY MANUAL ACKNOWLEDGEMENT FORM

ACTIVITIES PERMISSION

SUNSCREEN PERMISSION

TRANSPORTATION AUTHORIZATION

PUBLICITY/PHOTOGRAPHY/VIDEO RECORDING RELEASE

BEHAVIORAL MANAGEMENT PLAN