PVYC Summer Camp Registration Form 2

PVYC Summer Camp Registration

Summer 2025
Camper Information
Camper's Name*

First NameLast Name
Age*
Birth Date*
Fall Grade*
Campers grade must fall between entering 3rd through entering 9th
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Home Number
Format: (000) 000-0000.
Cell Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship to Camper*
Phone Number*
Format: (000) 000-0000.
Emergency Contact's Name*

First NameLast Name
Relationship to Camper*
Phone Number*
Format: (000) 000-0000.
Travel Information

(Please list individuals who are permitted to pick up your child other than parents/guardians & emergency contacts)
Names:*

Medical Information
Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe severity, triggers, and treatment.*
What medication may we give your child? (Tylenol, Children’s Benadryl, etc.)*
Is your child prescribed an inhaler? If yes, please explain any instructions.*
Does your child have any physical restrictions? If yes, please list restriction and reason.*
Insurance Carrier:*
Policy Number:*
Insurance Phone Number:*
Policy Holder Name:*
Medical Release
To the best of my knowledge this medical information is accurate. I grant permission for my child to attend camp and participate in all activities unless otherwise specified. As parent or legal guardian, I accept the conditions stated, including the release of PVYC from liability in the case of injury or illness. I give permission to the hospital and medical personnel selected by PVYC authorities to order treatment for my child. In the event I cannot be reached by PVYC, I give permission to the physician selected by PVYC to render whatever emergency treatment judged necessary, to hospitalize and secure proper treatment for the child named on this application. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes.*

I agree to the medical release.I do NOT agree to the medical release.

Photo Release
I understand that the photograph, video and/or audio recording taken of my child by counselors, directors or other campers may be used in connection with PVYC. I grant PVYC, its employees, agents and assigns, the right to photograph my dependent and use the photo and/or other digital reproduction of him/her or other reproduction of his/her physical likeness for publication processes, whether electronic, print, digital, or electronic publishing via the internet.*

I agree to the photo release.I do NOT agree to the photo release.
Camp Shirts

Campers will be given ONE shirt for the summer. Camp Shirts are sponsored by Penn United Technologies.
Shirt Size (Please specify if you are requesting a youth or adult size.)
Camper Contract
Parents/guardians, please read over the following rules with your child and explain that these rules must be followed by all children at PVYC during the summer program.
1. Campers must sign in each morning and their parents/guardians or approved driver must sign them out. No child is permitted to leave PVYC outside of this procedure.
2. All campers must turn in all medications with instructions to a counselor upon arrival to camp.
3. PVYC is a drug-free, smoke-free, and alcohol-free property.
4. PVYC is not responsible for any damaged, lost or stolen items. It is highly suggested that children do not bring any valuables with them to camp and that they keep their money and cell phones in a safe place.
5. Campers must treat staff members and each other respectfully. Put-downs, foul language, fighting, and public displays of affection will not be tolerated at PVYC.
6. No weapons of any kind, including pocket knives, will be permitted at PVYC.
7. For the safety of all the campers, no one will be allowed to leave a monitored area without permission from a counselor.
8. All campers must take part in the daily activities as well as camp cleanup.
9. All equipment at PVYC must be used for its intended purpose only.
10. Music with profanities and/or immoral themes will not be permitted.
I have read the following rules to my camper; My camper and I agree to the "Camper Contract"
Discipline for Infractions
Disciplinary actions will be taken based upon the severity of the infraction. Parents will be notified of the action taken. Disciplinary measures may include, but are not limited to:
- Verbal warnings
- Loss of store privileges
- Temporary suspension of camp and/or Fun Fridays for the length of time deemed appropriate by the staff.
- Assigning the cost of damages/repairs in the event of damage or destruction of PVYC property.
- Releasing individual(s) to the nearest law enforcement agency or proper authorities.
I understand that if a behavioral problem occurs, a staff member will call a parent/guardian to inform them of the incident.

Early Drop-Off / Late Pick-Up
Early drop-off and Late pick-up is available for an additional cost of

$40.00 A WEEK PER CHILD.

Early Drop-Off Hours: 8:00-9:50 am.

(Camp Hours: 10-4)

Late Pick-Up Hours: 4:15-5:00 pm.

Service must be requested on a weekly basis. Staff will not be at camp if service is not requested in advance.
Yes, this is a service that we will request weekly.We will occasionally need this service and will request when needed.No, we will drop off at 10 am and pick up at 4 pm.
Camp Cost
Petroleum Valley Summer Camp costs $100 for our Monday through Thursday, 10am to 4pm, 8-week program. This cost includes daily activities, devotionals, a camp t-shirt, and much more! This cost will help ensure that PVYC will be able to continue to operate and grow in the years to come. Fun Friday Field Trips will not be included in this cost and will be offered at an additional charge. If you are registering more than one child, please note that the first child will cost $100, the second will cost $95, and each child after will cost $90.*

I agree to paying the appropriate amount ($100, $95, or $90) for my child to attend summer camp.
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.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

PVYC Summer Camp Registration

Camper Information

Medical Release

Photo Release

Camp Shirts

Camper Contract

Discipline for Infractions

Early Drop-Off / Late Pick-Up

Camp Cost