The Vault Academics Summer Camp 2022 Registration Form

Student Registration Form

Welcome to The Vault Academics S.T.E.A.M Summer Camp registration! The Vault Academics is a licensed Child Care Center providing, our S.T.E.A.M based summer camp for k-5 provides students hands on learning opportunities in the areas of Science, Technology, Engineering, Arts and Math. Please fill the form below in its entirety to complete student registration. Due limited space, we will only be offering our summer camp to those enrolling full time (monday-friday) and preference is given to those who register for 6 (six) or more weeks. You may also request a PDF version of this registration by emailing: TheVaultAcademics@gmail.com or calling/texting 203.632.9651.
Summer Camp Details

Hours: 8:00 am - 6:00 pm

8:00 am- 9:00 am- Drop Off

9:00- 4:30pm S.T.E.A.M Program

5:00pm-6:00pm- Pick Up

Grades k-5th (As per 2022-2023 school year)

*5 yr olds must have completed kindergarten.

Rates:

Weekly Rate: $199/week

*$150 per additional sibling

Summer 2021 Camp Dates:

June 27th- August 19th
*Limited to 10 children (15 maximum)
** Care4kids accepted
***Two snacks (morning and afternoon) provided daily, lunch is provided by parent/guardian
**** Field Trips: We have a variety of inhouse (Virtual Reality) field trips, mobile field trips, as well as trips to the outdoors (Quassy, CT Science Center, maritime aquarium) which will take place on a weekly basis. In addition we will have themed weeks.
Student’s Name

First NameLast NameGrade
Date of Birth

MonthDayYear
Date
Gender
School Grade
Student’s School Name
Student's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student’s E-mail
example@example.com
Student’s Mobile Number
Format: (000) 000-0000.
Mother's Information/Guardian

First NameMiddle NameLast Name
Mother's Phone Number
Format: (000) 000-0000.
Mother's Email Address
example@example.com
Mother's Employer and Phone Number
Father's Information/Guardian

First NameMiddle NameLast Name
Phone Number
Format: (000) 000-0000.
Father's Email Address
example@example.com
Father's Employer and Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Health Insurance Information

CarrierPolicy #Name Insured Under
Primary Care Physician
Primary Care Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dentist
Dentist Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contacts
The following local contacts will be contacted in the event of an emergency and neither
parent/guardian can be reached. There must be a minimum of two emergency contacts
per licensing guidelines.
Emergency Contact #1 (other than parent)

First NameMiddle NameLast Name
Relationship to child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2 (other than parent)

First NameMiddle NameLast Name
Relationship to child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Information
Daily Medications
Medical Conditions
Allergies
As the parent/guardian of the child listed above, I give The Vault Academics' School Age Program permission to transport the child to the closest hospital for
proper treatment by any licensed physician including anesthesia and surgery if
medically necessary.
Parent Name
Parent's Signature
Registration Information

Please select Programs of interest
Please select the weeks you would like to enroll your child for.

Other
Please let us know if you are in need of special accommodations, have comments or concerns
By signing you below, you attest to the information above is correct and you will update as necessary. Your registration will not be complete until this form, the $25.00 non-refundable registration fee, your child’s current health assessment with
vaccinations, and a copy of their insurance card is turned into The Vault Virtual Reality School Age Program.
It is the responsibility of the parent/guardian to complete the registration and enrollment will be on a first come, first serve basis.
The Vault Virtual Reality School Age Program is open for enrollment for children who are currently attending kindergarten through 5th grade. The Vault Virtual Reality School Age Program does not discriminate on the basis of race, sex, religion, national origin, or ancestry in admissions, employment, or otherwise. Please do not hessitate to contact us via phone, e-mail or text, we are happy to hear from you!

thevaultacademics@gmail.com or 203.632.9651
Parent/Guardian Name Printed
Signature
THE VAULT ACADEMICS SCHOOL AGE PROGRAM STATEMENT OF VOLUNTARY CONSENT, GENERAL RELEASE OF LIABILITY, WAIVER OF CLAIMS, EXPRESS ASSUMPTION OF RISKS, AND HOLD HARMLESS AGREEMENT
I blanks , parent  or  guardian  of blank , agree  for  myself  and  my  minor  child,  and  my  estate,  heirs,  administrators,  executors
and  assigns,  hereby  release,  discharge  and  hold  harmless  The  Vault  Virtual  Reality
School  Age  Program,  including  their  administrators,  directors,  teachers,  and  staff  for,   from,  and  against  any  and  all  liability  and  responsibility  for  any  and  all  damages,  claims,   that  my  minor  child  or  I  may  have  lost,  including  injury  or  death  that  was  sustained  at  no   fault  or  negligence  of  The  Vault  Virtual  Reality  School  Age  Program  staff.  I  have   provided  my  child’s  medical  history  accurately.  I  have  also  read  and  acknowledge  this  agreement  and  have  signed  this  document  voluntarily  with  careful  consideration.  I  am  also  certifying  I  am  at  least  18  years  old,  fully  competent,  and  I  am  the  parent  or  appointed  legal  guardian  of  the  child  listed  above.
Parent/Guardian Name Printed
Signature of Parent/Guardian
Covid-19 Policies and Procedures for The Vault Academics School Age Program. To prevent the further spread of the Covid-19 pandemic and promote the safety of our children, staff and community, The Vault Academics' School Age Program has adopted these Covid-19 Policies and Procedures under the guidance of the Office of Early Childhood licensing regulations. The policies and procedures listed below may be increased or relaxed over time based on the situation of the pandemic, as the situation is fluid.
Group sizes will be no greater than 18 children per 2 staff to accommodate social
distancing. There will be no intermingling between groups with staff or children.
The spaces in use will be deeply cleaned and disinfected before another group
uses the space. All rooms will also have hand sanitizer and the children will
frequently wash hands which include washing hands and sanitizing upon arrival
and dismissal.
- All staff, children, and visitors will have a health screening upon arrival.
- If anyone including children and staff have a fever over 100.4 degrees
fahrenheit they will not be permitted into the center.
- All visitors including children and staff must answer the following
questionnaire relating to the past 5 days. Has the person had:
- Fever or chills
- Cough
- Shortness of breath or difficulty breathing
- Fatigue
- Muscle or body aches
- New loss of taste or smell
- Headache
- Sore throat
- Congestion or runny nose
- Nausea or vomiting - Diarrhea
- Rash
- Exposed to Covid - 19
- Have you traveled internationally within the past 14 days?
- Have you visited any of the states listed on the State of
Connecticut’s travel ban list in the past 14 days?
If anyone answers yes to any of these questions, the child or staff will not be allowed into the center, and can only be admitted if they can answer no to the questions . - The center staff will monitor signs of illness from children, staff, and visitors alike.

- If a child shows any signs of illness, they will be immediately removed and
brought into a designated “sick area” away from others until they are
picked up. The child will be supervised at all times and the area will be
deeply cleaned after use.
- If a staff becomes ill, they must immediately go home and another staff will
be called in to remain proper ratios.
- If either a child or a staff member becomes ill, the ill person must follow up with a
physician and get documentation proving the illness is not related to Covid - 19
and then will be allowed to return after 72 hours of the diagnosis. If the physician
is unable to provide documentation, the child and all household members will not
be able to return to the program for 14 days and they will need to self-quarantine.
- Face masks must be worn at all times by staff and children both inside and
outside.
- If a child or staff arrives at the center without a face mask, one will be
provided to them.
- Face coverings must cover the nose and mouth at all times unless
drinking or eating. An exception is only for those who have a medical
exemption with proper documentation.
- Children will be offered mask breaks when possible outside, at least 6 feet
apart. The children will keep their masks in labeled bags.
- Social distancing will be strictly enforced. Staff and children need to maintain the
minimum of 6 feet from one another which includes staggered arrival, departure,
and lunch times.
- There will be regular handwashing by staff and children for at least 20 seconds at
key times. - Hands will be washed:
- Upon entering the center
- Before and after eating
- After sneezing, coughing, and blowing of the nose
- After using the restroom
- Before handling food
- After touching a contaminated surface
- Before and after using shared equipment such as toys, computers,
etc.
- If soap and water are not available, an alcohol based sanitizer will be
used. The staff will directly supervise the children using any alcohol based
hand sanitizers.
- All staff must cover coughs and sneeze with tissues or the corner of their elbow,
and children will be encouraged to cover coughs and sneezes in the same
manner.
- Soiled tissues are to be immediately disposed of.
- The center will have enhanced cleaning and disinfecting practices between
groups of children and common areas. - All staff, children, and visitors must wear gloves when using common
equipment. - There will also be a nightly deep cleaning and disinfection of all areas. - There will be regular disinfecting of surfaces before and after use for
everyday activities including for homework, crafting, etc. - All toys and supplies that have been used will be placed in a soiled
container and will be disinfected nightly. - Entry to the program is limited. At this time, we ask parents to wait outside the door and a staff member will meet you to admit or dismiss your child. The Vault Academics' complaint procedure per the Office of Early Childhood licensing policy will be posted for viewing on the door for all visitors and parents. To maintain the safety of all our children and staff, there will be no visitors including parents permitted into the building during operating hours.
- If a child or staff affiliated with the center has been diagnosed with Covid - 19:
- All families and staff will be notified of the exposure while keeping the
name of the positive person confidential.

- The diagnosis will be immediately reported to the DPH Epidemiology and
Emerging Infection Program (860) 509-7994 and the local health
department to start contact tracing procedures. It is possible children and
staff are ordered to self quarantine and the center may have to close parts
or the whole center based on the exposure and guidance from the local
health department.
I have read, understand, and agree to the policies and procedures set forth by The Vault Academics' School Age Program to contain the spread of the highly infectious
disease. I have been informed of the risk of Covid - 19 and consent to the participation
of my minor child in The Vault Academics' School Age Program. I have also received
notice of the following:
● People who are 65 years and older and people of any age with serious underlying
medical conditions or are at higher risk for severe illness from Covid - 19 are recommended to stay at home. A list of medical conditions associated
with a higher risk of severe illness from Covid - 19 can be found in the CDC’s guidance.
Individuals and families should consult their healthcare provider to determine whether
they have medical conditions that place them at risk.
● Staff and children living in households with individuals who are 65 years and older OR
have higher risk for severe illness from Covid - 19 are recommended to stay home .
Child's Name Printed
Parent/Guardian Printed Name
Today's Date

MonthDayYear
Date
Signature
Should be Empty:

Student Registration Form

Emergency Information

Registration Information

THE VAULT ACADEMICS SCHOOL AGE PROGRAM STATEMENT OF VOLUNTARY CONSENT, GENERAL RELEASE OF LIABILITY, WAIVER OF CLAIMS, EXPRESS ASSUMPTION OF RISKS, AND HOLD HARMLESS AGREEMENT