2022 Summer Camp Form

2022 NPC Christian Preschool Summer Camp Registration Form
***ALL SUMMER CAMP WEEKS ARE CURRENTLY FULL. WE ARE KEEPING A WAIT LIST SO WE WILL CONTACT YOU REGARDING PLACEMENT ON THE LIST ONCE WE RECEIVE YOUR REGISTRATION. THANK YOU!***

Narberth Presbyterian Church Christian Preschool is pleased to offer summer camp for 2022! Here are the details:
- Camp will run for 6 weeks beginning Monday, June 27 and ending August 4, 2022.
- Camp will be Monday thru Thursday, with the exception of the week of July 4th when it will run Tuesday thru Friday.
- Depending on enrollment, we will offer 3 groups: Toddlers, Threes/Young 4s, Older 4s/Rising Kindergarten)
- Camp will meet 9am – 1pm for all groups.
- Campers should pack a nut-free snack and lunch each day.
- Camp activities will include outdoor play, art club, music, sports, STEM activities, cooking, water play, walking field trips and more!
- There is a requirement to select at least 3 weeks, and if you choose all 6 weeks, there is a $50 discount.
- Tuition for children 18 months - 3 years (not toilet-trained) is $160 per week.
- Tuition for those over the age of 3 (must be toilet-trained) is $145 per week.
- There is a $50 registration fee.
- Current families will be invoiced over Brightwheel. New families should mail the registration fee to NPC Christian Preschool, 205 Grayling Avenue, Narberth, PA 19072 (Attn: Virginia Davis)
- Summer camp tuition is due in full by June 1, 2022.

Child's Information
Name *

First Name Last Name
Date of Birth *

Month Day Year
Sex *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent # 1 Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent # 2 Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Enrollment

(Select One Option)
Toddler (18months by the start of camp-3 not yet potty-trained)
3 & Up Potty-trained
Please select the weeks you would like your child to attend summer camp (3 week minimum in order to enroll).

I would like my child to attend all 6 weeks and receive a $50 discount. Week 1 June 27 - June 30 Week 2 July 5 - 8 *Note this week meets Tues-Fri Week 3 July 11 - 14 Week 4 July 18 - 21 Week 5 July 25 - 28 Week 6 Aug 1- 4
Please select a payment method
Emergency Contacts
Parents are the first emergency contacts. List the name of at least three additional people who can be contacted in the event of an emergency or illness if you cannot be reached. These individuals will also be approved pickups. Any person listed should be able to assist in contacting you, able to take responsibility for the child in case the parent/guardian cannot be contacted, and should be at least 18 years of age with proper identification.
Emergency Contact #1 *

Name Relationship to child
Phone Number *

Area Code Phone Number
Emergency Contact #2 *

Name Relationship to Child
Phone Number *

Area Code Phone Number
Emergency Contact # 3 *

Name Relationship to Child
Phone Number *

Area Code Phone Number

Medical/Health Information
Name of Physician or Clinic/Hospital *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Insurance Provider *
Insurance Policy # *
Does your child have any Special Disabilities? *

Yes No
Does your child have any allergies? *

Yes No
Does your child have a special health or medical condition? *

Yes No
If you answered yes to the question above, please provide a brief summary of their condition.
First Aid and Emergency Medical Care Consent
Child's Name *

First Name Last Name
Today's Date *

Month Day Year
Date
My full signature below authorize staff in the program who are trained in the basics of first aid to give my child first aid when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. I also understand that all incidents will be recorded in an incident/medication log. However, if I cannot be reached, I hereby authorize to transport my child to the nearest medical care facility and to secure necessary medical treatment for my child. I understand that I assume all financial responsibility for any treatment or injuries sustained by my child while he/she is in the program.
Full signature below to consent to first aid and emergency medical care for my child *

Clear
Is your child currently using any medication? If yes please explain. If no type "N/A'. *
I understand that it is my responsibility to provide an up-to-date health form (included at the beginning of this form) for my child. This form must include my child's up-to-date vaccinations, the date of their last physical and a signature or e-signature from their doctor.* *

Yes No

Photograph/Media release authorization on behalf of Christian Preschool
YES, I do give permission to have my child appear in any media coverage (t.v., newspaper articles, photographs, website) on behalf of Christian Preschool. *

Yes
Walking Field Trips & Water Play Permission
YES, I do give permission to allow my child to attend walking field trips and to participate in outdoor activities such as water day. I understand that it is my responsibility to send my child with all required items for special activities. *

Yes
Please note any special accommodations for your child.

Parent/Guardian Agreement

Please review the following policies and initial each.
General Policies

I am enrolling my child in 2022 Summer Camp at Christian Preschool.
I understand that there is an application fee of $50.
I understand there is a tuition fee which is due by June 1, 2022 date via Brightwheel or by check. I understand that I am responsible for processing fees occured by Brightwheel for online transactions.
I understand that NPC Preschool will be providing camp from the hours of 9:00 AM - 1:00 PM.
I understand that my child will not be dismissed from the program without being picked up by a parent-designated adult.
I understand there will be a $15 fee will be added every 15 mins for any late pick-ups.
I understand that if a medical emergency arises, program staff will attempt to contact parents or the emergency contact that I have indicated. It is the parent’s responsibility to notify the staff if this information changes. If immediate medical attention is necessary, an ambulance or emergency vehicle may take my child to the hospital of their choice.
In cases of illness, I understand that my child may not be permitted to attend the program. If staff feels that a child has a contagious disease, he/she may not return to the program without a doctor’s note.
In order for my child to be considered for this program I understand that I must complete all enrollment paperwork and health assessments.
I understand that the Christian Preschool Summer Camp program is faith-based (Christian).
I have received complete program information (handbook) at the time of enrollment (PA Code 3270.121, 3280.121, 3290.121)
I agree to update the emergency contact and parental agreement when changes occur or every 6 months at a minimum. (PA Code 3270.124, 3280124., 3290.124)
I have read and understand the General Policies (Full signature) *

Clear
Non-Discrimination in Services
SUBJECT: Nondiscrimination in Services

TO: Parents/Guardians

FROM: Virginia Davis, Director

Admissions, the provisions of services and referrals of clients shall be made without regard to race, color, religious creed, disability, ancestry, national origin (including limited English proficiency), age or sex.
Program Services shall be made accessible to eligible persons with disabilities through the most practical and economically feasible methods available. These methods include, but are not limited to, equipment redesign, the provision of aides and the use of alternative service delivery locations. Structural modifications shall be considered only as a last resort among available methods.
Any individual/client/patient/student (and/or their guardian) who believes they have been discriminated against, may file a complaint of discrimination with:

Narberth Presbyterian Church Christian Preschool
205 Grayling Ave
Narberth, PA 19072

Commonwealth of Pennsylvania Department of Human Services Bureau of Equal Opportunity
Room 225, Health & Welfare Building P.O. Box 2675
Harrisburg, PA 17105

Commonwealth of Pennsylvania Department of Human Services Bureau of Equal Opportunity Southeast Regional Office 110 N. 8th Street, Suite 501 Philadelphia, PA 19107

PA Human Relations Commission
Harrisburg Regional Office
333 Market Street, 8th Floor Harrisburg, PA 17101

U.S. Department of Health and Human Services
Office for Civil Rights
Suite 372, Public Ledger Building 150 South Independence Mall West
Philadelphia, PA 19106-9111
I have read and understand the nondiscrimination in services notice (Full signature) *

Clear
Dismissal, Discipline, and Discharge Policy
Children are not permitted to arrive alone and must be escorted by an adult.
Children are only permitted to be signed out by an approved pickup over the age of 18.
The fee for late pick up is $15 per 15 minute interval. Excessive lateness will be reviewed.
Children are not permitted to bring any toys from home.
A child who displays chronically disruptive behavior may be suspended or discharged at the discretion of the camp supervisors.
Unacceptable Behavior of the child:
Spitting, biting, or hitting
Inflicting physical harm on other children or staff
Inappropriate language or drawings
Using profanities or obscenities
Ridiculing or bullying other children
Taking other children’s belongings
Destruction of school or personal property
Ignoring or disobeying the rules during the program times
I have read and understand the Dismissal, Discipline, and Discharge Policy (full signature) *

Clear
Sign Document (full signature) *

Clear
Please print the full name of the person completing this form.
Date Signed *
Should be Empty:

2022 NPC Christian Preschool Summer Camp Registration Form

Child's Information

Enrollment

Emergency Contacts

Medical/Health Information

First Aid and Emergency Medical Care Consent

Photograph/Media release authorization on behalf of Christian Preschool

Walking Field Trips & Water Play Permission

Parent/Guardian Agreement

Non-Discrimination in Services

Dismissal, Discipline, and Discharge Policy