Camp Kooky application

Camper Information

Camper's Name*

First NameLast Name

Which week will your camper attend?*

Birth Date*

MonthDayYear

Last grade completed (must have completed Kindergarten)*

Gender

MaleFemale

About Camper -- Least favorite activity

About Camper -- Favorite activity

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Parent/Guardian Name*

First NameLast Name

Contact Number*

E-mail

example@example.com

Parent/Guardian Name*

First NameLast Name

Contact Number*

E-mail

example@example.com

Emergency Information

Name*

NameRelationship

Phone Number

Please enter a valid phone number.

Name*

Namerelationship

Phone Number

Please enter a valid phone number.

Health Insurance

Isurance Company

Group #

Policy #

Physician Name:

Phone Number:

Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe. if none type N/A*

List any medications to be taken while at camp -- Medication name; dosage amount: and time to be given

I hereby give my consent for my child to have medications listed to be administered by Camp Kooky staff at the times indicated above*

Clear

Medical Release and Authorization As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the {Organization} . and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Parent signature*

Clear

Child pickup permission - Name of person allowed to pick your child up from camp

Name & Phone number

Child pickup permission - name of person that is allowed to pick up your child from camp

Name & Phone number

Photogtraphs and recordigns are taken as part of Camp Kooky. Do you give permission and authorixzation for the Island Community Center, and all groups, organizations, foundations, and individuals connecvted with Camp Kooky to photograph, rtape record, and.or film my child's image, likeness, vice, and or appearance for marketing, publicity, website publicaitons, all other media (including social media) and /or grant requests without restriction as to frequency or duration of usage.

The Island Commuity Center does not have complete ownership of the material produced by each organization. The Island Community Center shall have complete ownership of the images used for publication of each organization. Each organzation may use my child's image as described above in any medium, electronic or otherwise, in any way with promotion and/or wrk of said groups/organizations.

I hereby in advance release, waive, forever discharge, hold harmless and covenant not to sue the Island Community Center or any board of trustees in connection with the Island Community Center from and against any and all liablity for any harm or damage resulting for the use of my child's photograph, image or likeness.

Do you consent to have your child's image used for publication, promotion, or advetisment

Yes - I give permission for my child's photo to be usedNo, I do not give permission for my child's photo to be used

Child's name Birthdate

Parent/Guardian signature*

Clear

Phone Number

Please enter a valid phone number.

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by the Island Community Center during the selected camp week(s). I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Island Community Center . and all its respective officers, agents, and organizations contracted by the Island Community Center, its representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against Island Community Center . including all staff and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. I acknowledge there is a risk of being injured that is inherent in all sports activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Signature

Clear

READ, DISCUSS, & SIGN

The following codes of behavior is for all campers, no exceptions. It is our goal to provide a safe and secure environment for all campers, counselors, leaders and directors of the camp. The Code of Conduct is to help campers understand what we expect from each individual. We look forward to working together to provide a day camp that values caring, honesty, & respect.

All campers, directors, counselors and leaders will treat each other with kindness
All campers WILL listen and follow the directions given by camp directors, counselors, and guest leaders.
All campers and camp leaders, directors, and counselors will respect all other campers, camp leaders, directors, and counselors
All campers will respect camp property & camp leaders’, directors’, and counselors’ property.
All camp supplies will remain at camp unless needed for a field trip.
The Community Center building, furniture, equipment will be treated gently.
Campers will assist in clean up as directed by the camp leaders, counselors, and directors.
When changing or using the restrooms, all campers will respect privacy for themselves and others.
When changing or using the restrooms all camp leaders, counselors, and directors will respect the privacy of campers and themselves.
All campers, leaders, counselors, & directors will use appropriate language at all times. (If you are not sure of offensive nature privately ask a leader – they will make the decision at their discretion)
All campers will be responsible for their actions
All campers will represent Camp Kooky in a positive light while on field trips including but not limited to IHT hikes, YMCA swim lessons, Island Historical Society, P.E.R.C., & the Stonington library.
The following will not be tolerated – name calling, teasing, bullying, or harassment of any kind (physical or verbal) this includes but is not limited to sarcasm and negative attitude towards authority.
The following is not allowed on the grounds of the Island Community Center - knives, guns, weapons, matches, lighters, explosives, cigarettes,

illegal drugs, drug paraphernalia, alcohol, harmful substances, or any item that can be used to threaten or otherwise cause harm.

I AGREE TO FOLLOW THE ISLAND COMMUNITY CENTER’S CODE OF CONDUCT. I UNDERSTAND THAT IF I CHOOSE TO NOT FOLLOW THE GUIDLELINES, AS SET FORTH ABOVE, I MAY BE ASKED TO LEAVE CAMP FOR THE DAY, THE WEEK, OR THE SUMMER AT THE DISCRETION OF THE CAMP DIRECTOR AND COUNSELORS.

Signature of camper*

Clear

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature*

Clear

My Products

Camper depositREQUIRED for all campers. ESY campers will be waived.

$50.00

ESY campersPlease check here is you are an ESY approved camper. This will give us a heads up to look for paperwork. ESY campers are limited to the first 4 weeks only.

$ Free

Week 1 of Camp KookyJuly 10 - 14

$150.00

Week 2 of Camp KookyJuly 17-21

$150.00

Week 3 of Camp KookyJuly 24-28

$150.00

Week 4 of Camp KookyJuly 31 - August 4

$150.00

Week 5 of Camp KookyAugust 7- 11

$150.00

Week 6 of Camp KookyAugust 14-18th

$150.00

Child size small t-shirtOur goal is for all campers to get a t-shirt -- if you feel you cannot afford $5 for one, please contact Jeannie at 207-367-2735.

$5.00 Quantity

Child size medium T-shirtOur goal is for all campers to get a t-shirt -- if you feel you cannot afford $5 for one, please contact Jeannie at 207-367-2735.

$5.00 Quantity

child size Large t-shirtOur goal is for all campers to get a t-shirt -- if you feel you cannot afford $5 for one, please contact Jeannie at 207-367-2735.

$5.00 Quantity

Adult small size t-shirtOur goal is for all campers to get a t-shirt -- if you feel you cannot afford $5 for one, please contact Jeannie at 207-367-2735.

$5.00 Quantity

Adult size medium t-shirt Our goal is for all campers to get a t-shirt -- if you feel you cannot afford $5 for one, please contact Jeannie at 207-367-2735.

$5.00 Quantity

Adult size large t-shirtOur goal is for all campers to get a t-shirt -- if you feel you cannot afford $5 for one, please contact Jeannie at 207-367-2735.

$5.00 Quantity

Support camp Kooky shirt If you wish to support Camp Kooky by purchasing a t-shirt check here

$15.00 Quantity

Enter coupon

Total

$0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Camp Kooky 2023

Medical

Photo Release and Consent

Consent to Participate