Summer Camp Detailed Registration Form

Camp Chatter Application

Jacksonville Speech & Hearing Center presents our speech-language summer adventure for children ages 3-7! June 10th through July 26th. LOCATION - San Marco Church: 1620 Naldo Ave. Jacksonville, FL 32207
Participant's Information
Partcipants's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade as of August 2024*
If not in school, type n/a.
YesNo (children who are not potty trained are not eligible for this program)
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information

The participant lives with

Rows	Select All That Apply
Mom
Dad
Step-parent
Grandparents
Siblings
Other

Name of parent or guardian*

First NameLast Name
Primary Number*
Secondary Number
Name of parent or guardian

First NameLast Name
Primary Number
Secondary Number
E-mail*
example@example.com
Camp Weeks Sign Up

Please select the weeks you are interested in enrolling the participant.*

Rows	Selected Week
Week 1: June 10th - June 14th
Week 2: June 17th - June 21st
Week 3: June 24th - June 28th
Week 4: July 8th - July 12th
Week 5: July 15th - July 19th
Week 6: July 22nd - July 26th

Emergency Information

The emergency contact must be an adult.
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
Other Authorized Contacts

List other adults who are authorized to pick up the participant below.
Full name & phone number for other authorized contacts
Health Information
Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Is your child currently or has your child previous received speech-language services? If so, please describe them below.*
YesNo
Doctor/Doctors Office Name*
Doctor/Doctors Office Address*
Doctor/Doctors Office Phone Number*
Health Insurance Plan*
Health Insurance Member ID*

Camp Chatter Acknowledgements

Please carefully read through and acknowledge your understanding and acceptance of each section below regarding your participant.
Registration and Confirmation

I understand that the completion of this registration does not guarantee my child a spot in Camp Chatter. Registration will be reviewed and spots offered on a first-come, first-serve basis. When registration is approved for camp, Jacksonville Speech & Hearing Center will contact you to confirm the weeks selected and collect the deposit. I understand I must pay the deposit within one week of receiving my confirmation notice to secure my child's spot in Camp Chatter. If I do not pay the deposit within one week of receiving notice of confirmation, I understand my spot will be offered to the next applicant on the list and I will move to the bottom of the list.
Enter initials to acknowledge and accept registration and confirmation information.*
Drop-Off and Pick-Up

I understand, Jacksonville Speech & Hearing Center will provide detailed instructions regarding drop off and pick up prior to the start of camp. Currently, drop-off times are daily from 7:45 AM to 8:15 AM and pick-up times are daily from 11:30 AM to 12:00 PM. My child is not allowed to be dropped off prior to 7:45 AM or picked up later than 12:00 PM My child is not allowed to be dropped off without confirming a Camp Chatter staff member or volunteer is aware they are present for camp.

These are subject to change with written notification.
Enter initials to acknowledge and accept drop-off and pick-up policies.*
Medical Release and Authorization

As Parent and/or Guardian of the named participant, 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 participant. 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 Jacksonville Speech & Hearing Center and its affiliates including administrators, directors, therapists, and volunteers 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 program.

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.
Enter initials to acknowledge and accept medical release and authoization policies.*
Healthcare Services

Jacksonville Speech & Hearing Center is a healthcare organization, not a childcare provider. I understand the purpose of Camp Chatter is to enhance my child's speech-language skills. The primary focus is the speech-language needs of children. Camp Chatter will provide back-to-back group therapies focusing on language, articulation, sensory, and reading skills.

HIPAA & Privacy Practices Notice: https://shcjax.org/hipaa/
Enter initials to acknowledge and accept healthcare services and HIPAA/Privacy Practices Notice.*
Approval and Waiver to Participate in Activities

I hereby give my approval for my child’s participation in any and all activities prepared by Jacksonville Speech & Hearing Center during the selected camp dates. In exchange for the acceptance of said child’s candidacy by Jacksonville Speech & Hearing Center, I assume all risks and hazards incidental to the conduct of the activities and release, absolve, and hold harmless Jacksonville Speech & Hearing Center and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of participating in selected camp sessions.

In case of injury to said child, I hereby waive all claims against Jacksonville Speech & Hearing Center including all administrators, directors, therapists, and volunteers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all activities. Some of these injuries include but are not limited to cuts, bruises, and the risk of fractures.
Enter initials to acknowledge and accept waiver to participate in activites.*
Behavior and Sick Policies

The health and well-being of all participants are essential to a successful and positive program experience. I understand my part in that is to be mindful of my child's health and behavior. I will not bring my child to Jacksonville Speech & Hearing Center if they have a fever or symptoms of illness. I also understand aggressive behaviors will not be tolerated and if my child is aggressive or physical with another child, staff, or volunteer I may be called to pick-up my child and they can be permanently removed from the program.
Enter initials to acknowledge and accept behavior and sick policies.*
Promotional Consideration

I understand that Jacksonville Speech & Hearing Center will periodically take photographs to promote its services to the community. These photos may include me and/or my minor child. I authorize Jacksonville Speech & Hearing Center to use the photographs for their intended purposes. If you would like to decline, please enter "decline" instead of your initials. below.
Enter initials to acknowledge and accept promotional consideration. If you prefer to decline this option, enter "decline" below.*
Financial Responsibility

I agree to accept financial responsibility for all services rendered to me (or my child) by Jacksonville Speech & Hearing Center that are not covered by my health insurance plan. Payment for services/supplies not covered by insurance is due at the time those services/supplies are provided. If services are provided by my insurance, I understand that I will not be financially responsible for those services.

APPLICATION FEE - There is a one-time, non-refundable application fee of $30 due at the end of this application. After application completion, you will receive instructions to make your application payment. Applications without payment will not be reviewed.

COST OF WEEKLY SESSIONS - Camp sessions are $140 per week.

NON-REFUNDABLE DEPOSIT - A $20 non-refundable deposit will be due at the time registration in the camp is confirmed by the center for each week the participant is registered.

BALANCE DUE - The remaining $120 will be due the Friday before the start of each session.

DISCOUNTS AND REFUNDS - Discounts and make-up days will not be offered for participants who miss dates they are registered for. After payment is processed for a given session, it is non-refundable and non-transferable. Payment secures your position so we are unable to offer it to another participant.
Enter initials to acknowledge and accept financial responsibility.*
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.

I ALSO ACKNOWLEDGE ALL OF THE INFORMATION PROVIDED WITHIN THIS REGISTRATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Camp Chatter Application

Participant's Information

Camp Chatter Acknowledgements