The 21st Century Learning Academy 2023 online registration

Camper Current School*

Castle HIllsEisenberg

Camper Name*

First NameLast Name

Camper Date of Birth*

Camper Grade in Fall of 2023*

Camper Gender*

Camper Address (not required)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Legal Guardian Info

Parent/Legal Guardian Name *

First NameLast Name

Parent/Legal guardian: Email*

example@example.com

Parent/Legal guardian:Relationship to camper *

Parent/Legal guardian: Phone number (primary)*

Area CodePhone Number

Parent/Legal guardian: Phone number (secondary)*

Area CodePhone Number

Emergency Contacts

Emergency Contact #1: Name *

First NameLast Name

Emergency Contact #1: Relationship to camper *

Emergency Contact #1: Phone number (primary) *

Area CodePhone Number

Emergency Contact #1: Phone number (secondary)*

Area CodePhone Number

Emergency Contact #2: Name *

First NameLast Name

Emergency Contact #2: Relationship to camper *

Emergency Contact #2: Phone number (primary) *

Area CodePhone Number

Emergency Contact #2: Phone number (secondary)*

Area CodePhone Number

Release Forms

Media Release

I, as the parent or guardian of below-named child, hereby give SummerCollab and its employees, representatives, and authorized third party media organizations permission to print, photograph, and record my child for use in audio, video, film, or any other electronic, digital and printed media.

Media Release: Child's Name*

Parent/Guardian name*

By clicking "Yes I Agree", this will serve as my digital signature

Yes, I agree

Data Release and Consent

We hope you will allow your child to participate in SummerCollab’s study to measure our programming’s impact. This study will assess your child’s growth during both the summer and the academic school year; specifically, we will measure growth in literacy, critical thinking, and sense of self. Impact will be measured through data collected during the summer and data shared by the Colonial School District. Data sharing between SummerCollab and districts is only applicable to students who attend Colonial District Schools. If you agree to participate, SummerCollab will collect data related to literacy, critical thinking, and sense of self during your child’s participation in Tyler’s Camp at Castle Hills. Additionally, SummerCollab will ask the Colonial School District (if applicable) for your child’s test scores from 3 tests over the course of the last school year. SummerCollab will also receive data from an upcoming Fall 2023 test, in addition to basic demographic information. When SummerCollab sees school district data, it will be anonymized by ID number, and at no time will SummerCollab know the name of the student attached to the data. Your child’s privacy is our priority; all data sharing between SummerCollab and the school districts will be in full compliance with Family Educational Rights and Privacy Act (FERPA), the federal education data privacy law.

I hereby grant permission to Colonial School District to share with SummerCollab all requested forms and information, including my child’s emergency contact information, health forms, and relevant permissions. Additionally, I grant permission for the Delaware Department of Health and Social Services to share with SummerCollab and the Colonial School District all requested forms and information related to eligibility and receipt of public assistance for reporting purposes. I attest that my child is fit for and medically able to participate in Tyler’s Camp activities. I understand that Tyler’s Camp activities have inherent risks and on behalf of my child I hereby assume all risks and hazards incident to my child’s participation. In consideration for permitting my child to attend Tyler’s Camp, I hereby forever waive, release and give up any and all claims, demands, liability, damages, costs and expenses of any kind whatsoever, including property loss, personal injury, or wrongful death, against The Summer Learning Collaborative, Inc., Colonial School District and each of their respective agents, employees, officers, directors, participants, coaches, instructors, transportation providers, contractors, volunteers, other representatives, and heirs, which may arise from my child’s attendance at, participation in, or transportation to/from Tyler’s Camp.

Data Release and Consent: Child’s Name*

First NameMiddle NameLast Name

Data Release and Consent: Child’s DOB:*

Data Release and Consent: Home Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Data Release and Consent: Student Current School:*

Data Release and Consent: Current Grade level:*

By clicking "Yes I Agree", this will serve as my digital signature

Yes, I agree

First Aid/Emergency Medical Release

I give my permission to the Tyler’s Camp staff to administer basic first aid to my child when needed. I also understand that I will be informed of any injuries attained by my child when I pick him/her up from the program. The health history the school district has is correct and complete to the best of my knowledge and the camper described has permission to engage in all camp activities except as noted on the registration forms. I give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me/or my child. All important medical information for my child has been documented on the medical and individual care plan forms. In the event I cannot be reached in an emergency, I give permission to the physician selected by the camp director and/or nurse to secure and administer treatment, including hospitalization, for the person named above. This form may be photocopied for trips out of camp. In the event that I cannot be reached in an EMERGENCY, I give permission to the physician selected by the program director and/or nurse to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Screen Time Permission

My child may, as part of a scheduled activity, watch educational and/or program based programs or movies during the day and/or use a computer for up to one hour per day.

Dress

I understand that the below-named child will spend a portion of the day outdoors; weather permitting. I understand that appropriate attire for weather conditions and enclosed toe shoes must be worn and that sunscreen is my responsibility.

Meals and Snacks

I understand that breakfast and lunch will be provided by Tyler’s Camp, but I may choose to pack my child’s meals. I understand there will NOT be access to a microwave for food which needs to be heated. I also understand that campers will be NOT able to order or receive “take out” at Tyler’s Camp.

Electronics

I acknowledge that my child is responsible for any personal belongings that are brought to Tyler’s Camp. In addition, I understand and agree that Summer Collab/Tyler’s Camp is not responsible for any personal items regardless of the value that may be lost, stolen, or destroyed even if item is confiscated while a member is attending Tyler’s Camp.

I acknowledge that cell phones may not be used, must be turned off while at Tyler’s Camp and must be out of sight. In addition, I understand that personal electronics and other computer devices are not permitted at Tyler’s Camp. I understand that staff will confiscate any device that my child brings to Tyler’s Camp.

Child's Name*

First NameLast Name

This camper has*

permission to engage in ALL camp activitiesRESTRICTIONS on participation in camp activities

If you chose restrictions on participation in camp activities, Please explain why:

After-Care

My child will need aftercare:*

YesNo

After-Care: PAL of Delaware

If your child is interested in before and aftercare with the PAL of Delaware, you must download and complete the membership application at https://palde.org/membership/

After-Care: 4-H Afterschool Information

In the event both guardians cannot be reached in an EMERGENCY, I hereby give permission to the physician (by calling 911) selected by the 4-H Director to hospitalize, secure the proper treatment for and to order injection, anesthesia or surgery for my child. I understand that I will be financially responsible for the cost of said treatment.

Family Physician*

Family Physician: Phone Number*

Area CodePhone Number

CHILD RELEASE:
The following people are authorized to pick up my child and we understand proper identification at pick up (driver’s license) is required

Health Information Form

Child Name*

First NameLast Name

Child date of birth*

Allergies? food, insect, other*

YesNo

Diagnosis of asthma*

YesNo

Diabetes?*

YesNo

Seizures?*

YesNo

Heart problems?*

YesNo

Ear/hearing problems?*

YesNo

Behavior concerns?*

YesNo

Eye/Vision concerns?*

YesNo

Does your child require administration of medication during camp hours (8:30a-3:30p)? NOTE: All medication must come to camp in the original medical packaging or be accompanied by a doctor's note*

YesNo

If yes, please explain:

Information may be shared with appropriate school and camp personnel for health purposes. By signing below, you give the Tyler’s Camp Nurse permission to administer the above medication as needed.

By clicking "Yes I Agree", this will serve as my digital signature

Yes, I agree

The 21st Century Learning Academy is funded through 21st CCLC funds.