2022-2023 Love & Care Exceptional Children's Day Camps Application

2022-2023 Love & Care Exceptional Children's Day Camps Application

(Please print and fill in all information completely
Child's Name*
Sex*

MaleFemale
Add A Sibling
Add A Sibling
Sex

MaleFemale
Sex

MaleFemale
Ethnicity
Child's Exceptionality
Is Your Love Bug Potty-Trained?*
Home Address
School
Grade
IEP
or 504
Date of Birth

MonthDayYear
Date
Age on first day of camp
Parent(s) Name
Phone Number(s)
Primary Email Address (Invoices will be sent to this email address)
example@example.com

EMERGENCY CONTACTS

(Others that may be reached, if we cannot reach you)
Emergency Contact #1 Name
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Emergency Contact #2 Name
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Emergency Contact #3 Name
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.

Medical Information
Doctor's Name
Phone
Health Insurance Co.
Policy Number
Allergies
Medications
Special Needs
(Anything we should know about your child to ensure he/she has a good camp experience, private meetings with Director available upon request.)
Pick Up Information
People authorized to pick up child
People NOT authorized to pick up your child
People authorized to pick up child
People NOT authorized to pick up your child
People authorized to pick up child
People NOT authorized to pick up your child

Camper Personal Information
Please describe your child's Special Needs
Please describe any triggers and what makes your child happy.
When upset, what behavior does your child display?
What calms your child down?
Allergies
Additional Details (Please Share Information Regarding Behaviors and Mannerisms)

Disclosures
Invoices must be paid by the due date, or your registration will be canceled, and you will lose your slot. Unfortunately, due to preplanned events and scheduled staffing, we are unable to issue any refunds. Please try to finalize plans before paying your invoice.

Late pick-up will result in a $25 per hour fee. Late fees will be assessed 15 minutes after the selected Camp has ended.

**NO PERSONAL ELECTRONICS PERMITTED i.e., Cell Phones, Ipads, Gaming Systems, etc., except those needed for Non-Verbal attendees. If any electronics are sent with your child, we will lock them up in safekeeping, until pickup.

By signing this document, I verify that I have read through the Love & Care Exceptional Children’s Childcare packet in its entirety. I verify that I have gone through the pricing and payment schedule and understand the importance of paying invoices, by the due date. I understand that submission of this form AND payment secures my child’s slot.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
As the parent/guardian of the listed child, I authorize my child to participate in all activities. I permit Love & Care Exceptional Children’s Childcare LLC., to administer first aid, and in the event of an emergency, to secure a physician for any emergency treatment needed for my child. I understand that a conscious effort will be made to locate me or a close relative before any action is taken. I understand and accept that this expense is my responsibility. I also understand that it is my responsibility to carry primary accident and health insurance.a
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Photography Release

I understand that photos may be taken and used for websites, social media, and promotional purposes. If I object, I have marked the * no photos/no videos option below.
Photography Release

I prefer that no photos or videos be used.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date

Notice of No Liability and Acknowledge

I understand that I am being informed in writing, by signing this acknowledgment that this facility does NOT carry liability insurance to protect my child in the event of Covid-19, injuries, illnesses, accidents, etc. Love & Care Exceptional Children’s Childcare LLC., Love & Care Exceptional Children’s Summer Camp LLC., Love & Care Exceptional Children’s Love Bug Music Club, The T.Y.L.E.R Movement, or any of its other affiliates are NOT responsible for injuries, illnesses, accidents, medical costs, lost wages, etc.
Signature

Clear
Date

MonthDayYear
Date
Bright From the Start Exemption Acknowledgement

This acknowledgment serves as a notice, that Love & Care Exceptional Children’s Childcare LLC., is NOT a licensed daycare facility. I understand that this program is not required to be licensed by the Georgia Department of Early Care and Learning and is exempt from state license requirements. The facility has been inspected by Columbia County Officials and each person volunteering and/or employed has gone through a thorough background check. Please sign below as an acknowledgment that you have received this notice.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Please read and initial the following statements:
There is a $100 fee charged for ALL returned checks.
No pro rating, one day is considered a full week. NO REFUNDS.
I received my parent handbook and understand that all rules are contained in it.

Intervention Behaviors (Verbal and/or Written Notification): This notification is only so that we can work together as a team, to reduce certain behaviors.
- Excessive screaming
- Sensory overload
- Perseverative behaviors that interfere with the class such as noises or singing
- Running away from staff (That puts themselves in danger)
Behaviors that Require a Parent Pick-Up:

Behavior that continues even after interventions have been tried and affects the safety of the child, other children, and/or staff. Some of these behaviors may include intervention behaviors listed above, as well as:
- Self-injurious behaviors
- Fighting with another student or staff member
- Inappropriate language
- Continuous non-compliance
- Spitting and/or intentionally using bodily fluids to be defiant
- Aggressive behaviors
Expulsion Behaviors: ALL Behaviors listed above, as well as:
- Repeated behaviors that require a parent pick-up and have not responded to
- Multiple interventions
**Aggressive behaviors towards Staff or fellow Consumers could be cause for expulsion. The program facility reserves the right to add to or change this list at any time*** Parents please be sure that you have read and understand the behavior policy. Any time an attendee is exhibiting behaviors that could injure themselves, staff, or other attendees or damage the facility or community property, Staff will call for the attendee to be picked up. Please understand that Love & Care Exceptional Children’s Childcare LLC. is not staffed to regulate severe behavior needs, as we are not a Behavioral Clinic or Therapy Center.
Does your child have a behavior plan?
I have read the attached copy of the behavior policy. I understand and agree with the behavior policy at Love & Care Exceptional Children’s Childcare LLC.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Medical Information

Pick Up Information

Camper Personal Information

Disclosures