Summer Camp Detailed Registration Form

Camper's Name*

First NameLast Name

Birth Date

MonthDayYear

What grade is your child going to in the fall?*

Needed for curriculum.

Gender*

MaleFemale

Parent/Guardian Information

Mother's Name*

First NameLast Name

Cell Number*

Please enter a valid phone number.

Father's Name

First NameLast Name

Cell Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail*

example@example.com

Does your family have MEDICAID?*

YESNO

Would you be interested in Social/Emotional learning opportunities for your child?*

YESNO

Emergency Information

Emergency Contact's Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Relationship*

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Name

First NameLast Name

Phone Number

Area CodePhone Number

Name

First NameLast Name

Phone Number

Area CodePhone Number

Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.*

Is the the camper prescribed an inhaler? If yes, please explain any instructions.*

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Gateway Summer Camp/Gateway Cathedral/OpenGate during the selected camp. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Gateway Summer Camp/Gateway Cathedral/OpenGate . and all its respective officers, agents, and 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 Gateway Summer Camp/Gateway Cathedral/OpenGate . including all coaches, counselors and affiliates, all participants, sponsoring agencies, advertisers, 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 sports or camp activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

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 Gateway Summer Camp/Gateway Cathedral/OpenGate . and its affiliates including Directors, Coaches, and volunteers and camp counselors 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.

BEHAVIOR MANAGEMENT

Gateway Summer Camp Our staff, while discouraging inappropriate behaviors, focuses on providing positive reinforcement for acceptable behavior, and encourages learning as a natural part of growth and development. We want each camper to have a positive experience at camp, and to experience as much as the camp session as possible.

We use a color chart to promote good behavior and for children to work toward receiving an incentive at the end of each week. Children start out on yellow each week and move to green by displaying good behavior. All children ending the week on green will participate in the end of the week incentive.

Accordingly, the following actions will be taken when addressing behavior that is unacceptable in a camp environment and their color will be moved by following the system below. Camp staff has the discretion to skip colors and move straight to purple or red based of the severity of the offense.

1. Reminder/Correction. “Please ask before….” (Yellow)

2. Verbal Warning. Counselors will be sure the camper understands why they are receiving a warning. Parents may be notified via the ABC log. (Yellow)

3. Timeout from their group/activity. Timeout length is equal to the camper’s age (a 6 year old will sit in timeout for 6 minutes). Parents are notified via the ABC log. (Orange)

4. Timeout with the Camp Supervisor or Camp Director. Incident is documented and parents are notified via phone. (Purple)

5. Camper is sent home for the remainder of the day. Parents will be notified and required to pick up their child immediately. (Red)

6. Camper is sent home for the remainder of the week. If a camper returns to camp, and the problem persists, they will be sent home for the rest of the week with no refund. (Red)

7. If a child is sent home for the week twice during the camp season, they will be removed from camp for the remainder of the season with no refund.

8. Fighting will not be tolerated! Children will be removed immediately for fighting and will be asked not to return. The safety of students and staff are our number once concern.

*Camp Director has the discretion to suspend/expel participant depending on the severity of the offense at any level.

Acknowledgement Form Behavior Management

I have read the rules, regulations and behavior management to my child. My child understands that they must follow these rules and strictly adhere to the policies to help make camp a safe program for everyone.

Please initial that you understand the behavior policy.*

Cell Phone Policy

1. No Cell Phone Use by Campers During Camp Hours
Campers are not permitted to use cell phones during camp hours, including during activities, meals, and group sessions. This helps promote full participation, social interaction, and safety.

2. Cell Phones Must Be Turned In Upon Arrival
All campers must turn in their cell phones to the Camp Office or designated staff during morning check-in. Phones will be securely stored and returned at the end of each camp day or week, depending on the program.

3. Emergency Communication
Parents or guardians needing to contact their child may do so by calling the Camp Director’s office or designated emergency line. Campers will be allowed access to their phones in emergencies, with staff supervision.

4.Prohibited Use
Unauthorized possession or use of a cell phone during camp hours may result in:

Confiscation of the device
Parent/guardian notification
Possible dismissal from the camp for repeated violations

5. Exceptions
Campers with documented medical or accessibility needs that require use of a phone or device must obtain written approval from the Camp Director before the first day of camp.

Rationale:

This policy ensures that all campers are:
Fully engaged in programming
Protected from online and social media distractions
Part of a healthy, technology-reduced environment that supports personal growth, creativity, and teamwork

Please initial that you understand the cell phone policy. *

Important Information

Camp Tuition: $65 per week, per child

Camp Hours: 9:00am-4:00pm (Monday - Friday)

Before Care: 7:30am-9:00am

After Care: 4:00pm-5:30pm

Camp Location: 5501 Olive Rd., Trotwood, OH. 45426 Phone: 937-823-8083

Closed for Independence Day: July 3, 2026

Closed for Juneteenth: July 19, 2026

Camp Administrator: Norman J. Scearce

nscearce@gatewaycathedral.org

Camp Secretary: Marla Andrews

mandrews@gatewaycathedral.org

Late Pick-up Policy for Gateway Summer Camp

A flat fee of $20.00 will be assessed to those individuals picking up off 4:00pm who have not signed up for after care.

A flat fee or $20.00 will be assessed to those after-care families picking up after 5:30pm

Things to bring to camp daily

Water Bottle
Closed-Toe Athletic Shoes
Lunches and Drink (Lunches will be refrigerated but no microwave is available) If packing
A Change of clothes
Gym Bag (to keep belongings in. If necessary.) *Please have your child’s name on all their belongings.

Please initial that you understand the late pick-up policy. *

PART I TO GRANT CONSENT AND VERFIY ALL INFORMATION ABOVE ACCURATE

In the event reasonable attempts to contact either parent or the emergency contact at the provided phone numbers have been unsuccessful, I hereby give my consent for the transfer of the child to ______________________________ (preferred hospital) or any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentist, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted: (Write below if applicable.)

PART II REFUSAL TO CONSENT

I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the authorities to take no action or to:

Please choose one.*

I DO give my consentI DO NOT give my consent

Camp Rules and Expectations

These rules and expectations are necessary so that we may enhance the enjoyment and safety of all participants.

1. To attend Gateway Summer Camp, children must be in grades K-6 for current school year. Children must: Child’s Pick Up List Emergency Medical Form Offsite Activity Waiver Acknowledgement Waiver

2. Use appropriate behavior and language at all times and will use materials and supplies in a safe and respectful manner.

3. Respect and follow the directions of camp staff.

4. Respect the Gateway property and the property of others.

5. There is absolutely no fighting or disruptive behavior. Please be sure to read the discipline procedure to your child so they are aware of the consequences. Fighting will not be tolerated. All students involved in fighting will be immediately removed from the program an unable to return.

6. All camp participants must stay within the designated boundaries of the camp as outlined by camp personnel.

7. The camp staff will not be responsible for the loss, damage or theft of personal items. Personal belongings should be labeled with child’s name. Campers MUST wear tie-on shoes (sneakers preferred). NO OPEN TOE SHOES, FLIP-FLOPS OR SANDALS. Please leave all valuable personal belongings (including jewelry) at home. Children are not permitted to bring toys, electronics, etc.

8. All camp forms must be signed by a parent or guardian and returned to the camp staff prior to your child’s first day of camp.

9. Camp staff will not administer medication.

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.

Date

Signature

Gateway Summer Camp Registration 2026

Camper Information

Child's Authorized Pick Up List