summer 2023 Agents of Change registration

Agents of Change summer program registration

program hours Tuesdays, Wednesdays, and Thursdays, 9:00am - 2:00pm, June 6-July 27; lead teacher Joele Newman joele.newman@peasleecenter.org
Please review all information carefully, complete any fields that are blank, and update anything that has changed. It is not necessary to complete the form in one sitting--if you need to pause and continue another time, scroll to the bottom of the form and click "Save." You will be sent an email with a link to continue the form, and all the responses you have entered so far will be saved.
Your name*
Phone (cell/primary)*
Phone (home/additional)
Phone (work/additional)
Email*
Race/ethnicity (please check all that apply)*

American Indian or Native AlaskanAsianBlack/African AmericanHispanic or LatinoMulti-racialNative Hawaiian or other Pacific IslanderWhite/CaucasianOther
Total number of people in your household*

2345678Other
Household of 2 income level

$32,227 or less$32,228-$52,260$52,261 or more
Household of 3 income level

$40,626 or less$40,627-$65,880$65,881 or more
Household of 4 income level

$49,025 or less$49,026-$79,500$79,501 or more
Household of 5 income level

$57,424 or less$57,425-$93,120$93,121 or more
Household of 6 income level

$65,823 or less$65,824-$106,740$106,741 or more
Household of 7 income level

$74,222 or less$74,223-$120,360$120,361 or more
Household of 8 income level

$82,621 or less$82,622-$133,980$133,981 or more
If there are 9 or more people in your household, please list the household's annual income
Fee Information

Based on your household size and income, you are eligible for a scholarship covering part of your camp fees. Your fees will be $50/week for one camper + $40/week for each additional camper. The fee payment schedule is as follows:
- payment 1, due no later than May 26: fees for weeks 1-5 ($250 for one camper + $200 for each additional camper)
- payment 2, due no later than June 23: fees for weeks 6-8 ($150 for one camper + $120 for each additional camper)
If you have questions or need to discuss a payment plan, please contact Liz Gottmer at liz.gottmer@peasleecenter.org or 513-621-5514.

Please note that these fees are in addition to the registration fees ($25 for one camper + $10 for each additional camper). You will receive details on how to pay registration and camp fees after you submit the registration form.
Fee Information

Based on your household size and income, your fees will be $100/week for one camper + $80/week for each additional camper. The fee payment schedule is as follows:
- payment 1, due no later than May 26: fees for weeks 1-5 ($500 for one camper + $400 for each additional camper)
- payment 2, due no later than June 23: fees for weeks 6-8 ($300 for one camper + $240 for each additional camper)
If you have questions or need to discuss a payment plan, please contact Liz Gottmer at liz.gottmer@peasleecenter.org or 513-621-5514.

Please note that these fees are in addition to the registration fees ($25 for one camper + $10 for each additional camper), which must be paid by March 22 to reserve your spot(s). You will receive details on how to pay registration and camp fees after you submit the registration form.
Street address*
Zip code*
Camper's first and last name*
Camper's date of birth*

MonthDayYear
Uh-oh! According to the date of birth you entered, this camper will not be between 13 and 15 years old in June 2023 and is not eligible for the Agents of Change program.
- If this camper will be 6-9 years old in June 2023, please click here to register them for the Peaslee Kids program.
- If this camper will be 10-12 years old in June 2023, please click here to register them for Peaslee's Risers program.
- If this camper will be 13-15 years old in June 2023, please check that you have entered the correct year in the date of birth field above.
- If none of these apply but you still think there is a mistake, please call Peaslee at 513-621-5514.
Current grade level*
School*
Gender*

malefemaletransgender maletransgender femalenon-binary/gender non-conformingOther
Personal pronouns
T-shirt size*
Your relationship to this camper*
Are you the camper's current legal guardian?*

yesno
If you are not the camper's current legal guardian, please enter the legal guardian's name and phone number here
What is the _first_ number we should call if we need to reach you while your child is in the program?*

cell/primaryhome/additionalwork/additionalOther
Emergency contact 1*
The parent/guardian completing this form CANNOT be listed as an emergency contact. Please list at least one other person who can pick your camper up from the program if you cannot be reached.
Emergency contact 1 phone number*
Emergency contact 2
Emergency contact 2 phone number
Please list any younger household members who will be turning 6 by June of 2024 and may be participating in Peaslee Kids next summer
Include name and date of birth
Signing in and out
Parents of participants in Agents of Change (ages 13-15) or Risers (10-12) may give their child permission to sign themselves into and out of the program. If you choose to give this permission, you understand and agree that:
- Risers and Agents must sign in/out at the scheduled start and end times of each program session. They may not sign out early unless a parent provides advance notice and coordination with Peaslee staff. Parents will be notified if their child leaves the program early without permission.
- Risers and Agents will not be supervised before signing themselves in or after signing themselves out. They may exit the building on their own and once they are past the front doors Peaslee staff is not responsible for knowing their whereabouts.
- Parents cannot stipulate that Risers or Agents may sign themselves out on the clipboard but must stay at Peaslee until they are picked up. Either they may sign themselves out and leave on their own, or an adult must come into the building to sign the clipboard.
May this camper sign themselves out of Risers/Agents of Change?

Yes, this camper may sign themselves out when program ends. I understand that they will no longer be under Peaslee's supervision and may leave the building once they have signed themselves out.No, this camper may only be signed out of the program by an authorized adult. Do not permit this camper to leave Peaslee's building by themselves.
May this camper sign their sibling(s) ages 6-9 out of Peaslee Kids?

Yes, this camper may sign their sibling(s) out of Peaslee Kids when program ends. I understand that the Risers and Agents of Change programs end earlier than Peaslee Kids, and that this camper will not be under Peaslee's supervision in between signing themselves and their sibling(s) out.No, my campers in Peaslee Kids may only be signed out of the program by an authorized adult.n/a, I have no campers ages 6-9
Please list the sibling(s) who may be signed out by this camper
Who is authorized to sign your camper out of the program?*
Please list names AND phone numbers of ALL people who may sign your child out--campers will not be released to anyone unless their name and contact information are shared with program staff in advance.
Health and medical background

If your camper takes any medication that will or may need to be administered during program hours, or has any conditions that require treatment/medical care if they are triggered during the program, you must bring the medication to Peaslee and train staff on all medical care instructions no later than Tuesday, May 30, 2023.
Camper's physician, clinic, or hospital*
Please include phone number
Can this camper swim?*

yesno
Please check any over-the-counter medications Peaslee staff may administer to your child in case of minor complaints

Ibuprofen/AdvilAcetaminophen/TylenolNeosporin antibiotic ointmentcalamine lotion
Please list any ongoing health or medical conditions*
You may type "n/a" if there are none
Please list any past or recent health concerns that would be important for staff and medical personnel to know in an emergency situation*
You may type "n/a" if there are none
Please list any environmental, seasonal, food, or medication allergies*
You may type "n/a" if there are none
Please list any dietary restrictions, including for medical, religious, or cultural reasons*
You may type "n/a" if there are none
Please list any additional information about your child that would be important for staff to know, such as fears, eating/sleeping habits, or special routines*
You may type "n/a" if there are none
If this camper has asthma or allergies, the next few questions will ask you to provide emergency care instructions in case their condition is triggered during camp. If you would like to see sample emergency care plans with common responses to these questions, please click here.
Does this camper have asthma?*

yesno
Does this camper use an inhaler?

yesno
Inhalers and any other medications that campers will or may need to use while they are in program must be provided to Peaslee before the first day of the program.
If this camper is at any risk of an asthma attack, Peaslee staff must be able to administer an inhaler or respond with another appropriate medical intervention. Please explain how this camper's asthma is controlled.
If the camper has "grown out" of their asthma, you will need to provide a doctor's note explaining that an inhaler is no longer needed.
Please list any activities, environmental conditions, or foods that should be avoided to prevent triggering this camper's asthma
What symptoms of asthma must Peaslee staff watch for?
What action must Peaslee staff take if these symptoms appear?
Include the name and dosage of any medications to be administered, and instructions for administering them
Does this camper have any allergies that cause anaphylaxis (affect their breathing or circulation)?*

yesno
Does this camper have an Epipen?

yesno
Epipens and any other medications that campers will or may need to use while they are in program must be provided to Peaslee before the first day of the program.
If this camper is at any risk of an anaphylactic attack, Peaslee staff must be able to administer an Epipen or respond with another appropriate medical intervention. Please explain how this camper's allergic reactions are controlled.
Please note that Peaslee takes food allergies very seriously and will make every effort to prevent exposure to allergens that affect our campers. However, in case of an accidental exposure, we must have access to whatever treatment is used to respond to a reaction.
Please list any activities, environmental conditions, or foods that should be avoided to prevent triggering this camper's anaphylaxis
What symptoms of anaphylaxis must Peaslee staff watch for?
What action must Peaslee staff take if these symptoms appear?
Include the name and dosage of any medications to be administered, and instructions for administering them
Does this camper have any other conditions that require treatment/medical attention if they are triggered during the program? Please check all that apply

seizuresseasonal/environmental allergiesskin sensitivity/eczemaOther
Please list any activities, environmental conditions, or foods that should be avoided to prevent triggering this condition
If you checked multiple conditions above, please complete this section with emergency care instructions for the first condition checked.
What symptoms of this condition must Peaslee staff watch for?
What action must Peaslee staff take if these symptoms appear?
Include the name and dosage of any medications to be administered, and instructions for administering them
Does this camper take any medication that will or may need to be administered during program hours?*

yesno
Name of medication
This medication... Check all that apply

is a prescription medicationis an over-the-counter medicationmust be kept refrigeratedis a lotion, ointment, or other product applied topicallyis a food supplement
When should this medication be administered? Check all that apply

at specific times of daywith mealsbefore physical activityas needed in response to symptomsfor a specific number of days (include in instructions below)Other
If the medication is administered at specific times of day, please list times here
Please note that campers should receive their first daily dosage at home before arriving at Peaslee
Dosage
Please specify exact dosage for this camper (e.g., 2 tablets/50mg).
Instructions for storing and administering medication
If a prescription medication is in its original packaging and should be taken as directed on the label, you may write "take as directed." Please be sure to include any special requirements for storage (e.g., medication must be kept refrigerated).
Do you need to add another medication?*

yesno
Name of medication
This medication... Check all that apply

is a prescription medicationis an over-the-counter medicationmust be kept refrigeratedis a lotion, ointment, or other product applied topicallyis a food supplement
When should this medication be administered? Check all that apply

at specific times of daywith mealsbefore physical activityas needed in response to symptomsfor a specific number of days (include in instructions below)Other
If the medication is administered at specific times of day, please list them here
Please note that campers should receive their first daily dosage at home before arriving at Peaslee
Dosage
Please specify exact dosage for this camper (e.g., 2 tablets/50mg).
Instructions for storing and administering medication
If a prescription medication is in its original packaging and should be taken as directed on the label, you may write "take as directed." Please be sure to include any special requirements for storage (e.g., medication must be kept refrigerated).
Do you need to add any more medical care instructions (including administering medication)?

yesno
Please click here to add more medical care instructions.
Participation Agreement

Please enter your initials in each section to show you have read and agree to each policy. Your consent here also applies to any new campers you register using the abbreviated form (linked on the confirmation page after you submit this form).
Schedule*
Campers are expected to attend at least 80% of program days. The program days for Agents of Change (Tuesdays, Wednesdays, and Thursdays) are different from the program days for Risers and Peaslee Kids (Tuesdays-Fridays). All Peaslee programs will be closed on Tuesday, July 4, 2023.
Program activities*
I give permission for my child to participate in all activities of the program and use all equipment these activities involve. I understand that some activities are outdoors and my child will be outside, even if there is light rain. I give permission for my child to go swimming or otherwise participate in water activities in and near bodies of water two feet or more in depth. During any such activity a certified lifeguard will be on duty at all times. I give permission for my child to walk to local swimming pools, and I will complete any additional consent forms for swimming/water activities at local pools. I give permission for my child to participate in any trips or excursions away from the program site. I understand that they may travel for these trips or excursions by walking, riding in a leased bus or vehicle, or riding public transportation.
Appropriate dress*
I understand that all participants should wear clothing that will allow them to move freely. Participants should wear sneakers or other closed-toe shoes so they can safely be active; flip-flops are not permitted I understand that they may NOT wear clothing with explicit or derogatory messaging, clothing that is overtly sexual or revealing, or clothing and/or accessories that may cause physical harm to themselves or other participants in the program.
Personal belongings*
I understand that participants may not bring electronics or toys from home. Items they may not bring include, but are not limited to: weapons, knives, illegal substances, hazardous or poisonous materials, unapproved medicine, electronic devices, iPods, or candy. Cell phones are permitted, but must be turned off during program hours to prevent unnecessary distractions. I understand that if my child brings anything inappropriate or distracting, it will be confiscated by the staff and returned to a parent at the end of the program day.
Safety, conduct, and discipline*
No camper is ever left alone or unsupervised. A telephone is available for emergency use at all times. I understand that my child is expected to follow and will be held accountable for all program rules. I understand that certain behaviors are not tolerated, including but not limited to: bullying; profanity; threats, intimidation, or harassment; disruption; disturbing the peace; dishonesty or misrepresentation; violation of criminal law; possession of weapons; possession of illegal substances (including alcohol, tobacco and other drugs); engaging in sexual activity or harassment; misusing photographic devices; and physical aggression. If my child is involved in these behaviors, I understand that I will be called to pick my child up immediately and they may be suspended from the program.
Behavior management*
Participants are expected to behave in a respectful and responsible manner. If a camper does not follow expectations, a staff member will hear their perspective and address what happened in a one-on-one conversation. Minor misbehaviors are part of growing up and learning to live with each other, and Peaslee does not make it a practice to report these. In more serious instances of aggressive or otherwise unacceptable behavior, staff will try to work together with the camper and a parent/guardian to help improve the behavior. However, Peaslee reserves the right to remove a camper from an activity or the entire program, without refund, due to conduct or for other reasons at any time during the program.
Illness and COVID precautions*
I understand that I may not bring my child to the program if they have a temperature of 100 degrees or higher; untreated rash or infected patches of skin; diarrhea or vomiting; stiff neck; or yellowish skin or eyes. If my child begins to experience any of these symptoms or other illness during the program, I understand that I will be notified and that my child must be picked up as soon as possible. I agree to notify Peaslee Neighborhood Center if my child is exposed to or contracts a communicable disease including COVID. Peaslee follows CDC recommendations for responding to COVID. If a camper shows symptoms during program, the camper's parent will be asked to test them for COVID. If a camper tests positive for COVID, their parent is expected to report the test result to Peaslee and follow CDC guidelines, which may include isolation and/or masking. If there has been COVID exposure within the program, Peaslee will notify parents of campers who have been exposed and recommend they be tested.
Photo release: I grant to Peaslee, its representatives and employees, the right to take photographs and audio/video clips of me and/or my child. I authorize Peaslee, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Peaslee may use such photographs of me or my child, with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content.*

YesNo
Program evaluation*
I understand that it is important to Peaslee to regularly evaluate and improve its programs, and that my child and I can help by taking about 15 minutes to complete a questionnaire at the end of the summer. I understand that participation is voluntary and whether or not my child participates will not affect their summer program experience. I understand that the information obtained will be confidential. I consent that my child may complete the program evaluation questionnaire at the end of the summer.
General release*
My child is responsible for all of their belongings. I understand that Peaslee is not responsible for personal property lost, stolen or broken while my child participates in the program. I understand that Peaslee is not responsible for anything that occurs as a result of false or incomplete information shared with program staff by a parent/guardian. I understand that medical expenses resulting from any illness or injury incurred while my child participates in any Peaslee program are my responsibility. Peaslee assumes no responsibility for injuries or illnesses which may occur as a result of a camper’s physical condition or as a result of their participation in any athletics, exercise, use of equipment, games or any other activities. I understand that there are inherent risks of injury in my child’s general participation in field trips, events, class sessions, and programming activities. I voluntarily assume and accept such risks of personal injury and illnesses arising from my child’s attendance and participation in such activities, field trips, events, and class sessions in Peaslee’s programs. I hereby release Peaslee, its trustees, employees and agents from all actions, claims or demands that I and my heirs or representatives now have or may hereafter have for personal injuries or property damage resulting from the child’s attendance and or participation in such activities and events. I/we agree that this release includes personal injury or property damages caused in whole or in part by negligence, active or passive, of Peaslee, its trustees, employees and agents. I understand that this release does not apply to liability for willful injury or fraud. I understand that permission and release shall remain effective through the end of the program year, until or unless I deliver a written revocation to the program director.
Should be Empty:

Agents of Change summer program registration

Signing in and out

Health and medical background

Participation Agreement