CAMP ALEXANDER - Crabapple (Campers with Special Needs)

CAMP ALEXANDER - Crabapple
CAMPER DEMOGRAPHICS
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
GENDER
Age At Camp Start
Grade Entering In September
School Attending
Camper T-Shirt Size
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parents/Guardians (Also allowed to pick up camper)
First Contact

First NameLast Name
Relationship to Camper
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Best Phone Number During Camp Hours
Please enter a valid phone number.Format: (000) 000-0000.
First Contact Email
example@example.com
Second Contact

First NameLast Name
Relationship to Camper
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Best Phone Number During Camp Hours
Please enter a valid phone number.Format: (000) 000-0000.
Second Contact Email
example@example.com
Camper ID/Photo Upload - Cheektowaga Residents 7 & up please upload the child's Resident ID Card (if the child does not have one you will need to get it before completing registration), Cheektowaga Residents Under 7 and Non-Residents please upload a photo of the child

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EMERGENCY CONTACT (if above cannot be reached)

*This person CAN also pick up*
Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Camper
RELEASE PERMISSION

(In Addition to those listed above)

Rows	Person's Name	Relationship to Camper	Phone Number
1
2
3
4
5
6

I have read and understand the Camper Release Procedure of the Town of Cheektowaga Department of Youth & Recreational Services, Summer Day Camps & Teen Club. Any changes I wish to make to the above list must be made through the Camp Director or Site Director.
Signature - Release Procedure
IMPORTANT:

In the case of custody and/ or visitation arrangements concerning the child named above, we must have copies of legal documentation on file in order to honor such arrangements. Otherwise, the Parent/Guardian named above who is registering the child will be the primary contact for the Cheektowaga Youth and Recreational Services Day Camps.
CAMPER INFORMATION
Has your child attended camp before?
Child's Primary Disability
Secondary Disability
Type of Classroom / Grade Level
Any difficulties with SIGHT
SIGHT - If YES please describe
Any difficulties with COMMUNICATION
COMMUNICATION - If YES please describe
Any difficulties with HEARING
HEARING - If YES please describe
Any difficulties with MOTOR SKILLS
MOTOR SKILLS - If YES please describe
How does the child express the need to go to the bathroom?
Does the child wear pull ups or diapers?
Is there a specific toileting program that we need to follow?
TOILETING - If YES please describe
FEMALE CAMPERS ONLY - Has your child started to menstruate?
If YES can she care for herself and if not please describe assistance needed
Behavior/Social/Emotional Needs - What methods of direction, support, or specific strategies do you find most effective?
What do you feel are your child's greatest needs?
Does your child have any special fears or worries?
If YES please explain?
Please list any Hobbies, Special Interests, or Favorite Things
Please list any additional information that will help us better work with your child and meet their needs.
REGISTRATION SELECTION

Select Camper Registration Weeks/Days Camp Dates are July 6 - August 14
Cheektowaga Resident
Residential Parent/Guardian Resident ID Card - Upload Current Card (If you do not have one or it is expired you will need to get one before completing registration)

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2026 Field Trip Schedule

7/10 WEEK 1: PICNIC IN THE PARK W/ INFLATABLES

7/17 WEEK 2: BEAVER ISLAND BEACH

7/24 WEEK 3: RAINBOW RINK

7/31 WEEK 4: EVANGOLA BEACH

8/7 WEEK 5: EXPLORE & MORE (A1-A3) & BOWLING (A4-A6)

8/14 WEEK 6: ERIE COUNTY FAIR
Day Camp Enrollment Selection
Which weeks will your child attend?
Week 1 Options
Week 2 Options
Week 3 Options
Week 4 Options
Week 5 Options
Week 6 Options
Early (7:30am)/Late Program (Until 5:30pm): $10 per week or $50 All 6 Weeks
Early & Late Program Policy and Procedures

All campers must be signed in and out of early/late program by the person dropping off or picking up. Early campers need to be signed in by a parent/guardian until 8:25 am. Late campers need to be signed out by a parent/guardian beginning at 3:45 pm. Only those individuals listed on the camper’s registration form will be allowed to pick up the camper and should be prepared to provide their ID until staff become familiar with them.

I realize that picking up my camper(s) by 5:30pm is an important responsibility on my part and that failing to do so will result in the following procedures:

A $5.00 fee per camper will be assessed for every 15 minutes a child remains at program past 5:30pm (ex. 5:31pm-5:45pm will be $5.00 per camper; 5:30pm-5:53pm will be $10.00 per camper). The first and second time this occurs; I will be informed that failing to pick-up my child on time may result in my child’s loss of late program services. The third time this occurs, I will receive written notification that my child will no longer be able to participate in late program.
Signature - Early & Late Program Policy
MEDICAL INFORMATION
A recent copy of Camper's Immunization Record needs to be included with Registration. Please upload here.

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Has your child been hospitalized in the past year?
If YES, for what reason?
Does your child have any allergies?
If YES, specify and list any care necessary?
Does your child have any special dietary needs?
If YES, specify.
Does your child have a history of seizures?
If YES, specify and list any care necessary?
Any other health related issues we should be aware of (recent illness, injury, restrictions, etc.)?
If YES, specify and list any care necessary?
Will your child require any medications to be administered during camp? All PRESCRIPTION AND OVER THE COUNTER MEDICATIONS REQUIRE DOCTOR'S ORDERS and MEDICATIONS MUST BE IN ORIGINAL CONTAINERS.
If YES, Specify Medication and dosing instructions?
PERMISSION FOR EMERGENCY MEDICAL ASSISTANCE
As the parent/legal guardian of the above mentioned camper, I hereby give permission to the Camp Health Director or designee, to seek emergency medical assistance for my child during camp.
Signature - Emergency Medical Assistance
PERMISSION FOR FIELD TRIPS / SWIMMING / SUNSCREEN
My above mentioned child is attending the Cheektowaga Day Camp/Teen Club program which is sponsored by the Cheektowaga Youth & Recreation Department and may be taken on all field trips planned by the program staff as well as participate in recreational swimming.
I give my permission for sunscreen to be applied at camp.
Signature - Field Trips, Swimming, Sunscreen
MEDIA

I hereby grant permission to record my child’s likeness and/or voice for use by television or print media if the opportunity presents itself for the day camp.
MEDIA PERMISSION SELECTION
WALKER/BIKER PERMISSION

*Complete this section ONLY if your child is close enough and old enough to walk or bike home from camp.*
Please issue a walker/biker pass.
Address Going To

Street Address

City

Postal / Zip Code
Phone Number of Parent/Guardian
Please enter a valid phone number.Format: (000) 000-0000.
Time child should be released from camp

Hour Minutes

AM/PM Option

FREE BREAKFAST & LUNCH PROGRAM INFORMATION
THIS SUMMER, THE ALEXANDER DAY CAMP WILL BE ONCE AGAIN BE PROVIDING FREE BREAKFAST & LUNCH TO ALL PARTICIPANTS AS PART OF THE SUMMER FOOD SERVICE PROGRAM SPONSORED BY THE NEW YORK STATE EDUCATION DEPARTMENT.

CHILDREN WILL RECEIVE NUTRITIONALLY BALANCED MEALS (BASED ON STATE & FEDERAL STANDARDS), MONDAY THRU FRIDAY DURING THE COURSE OF THE CAMP.

COMPLETE THE BOX BELOW TO MAKE YOUR SELECTION.

PLEASE NOTE: THE MEAL PROGRAM CANNOT ADJUST MENU TO ACCOMODATE FOR FOOD ALLERGIES

IF YOU CHOOSE NOT TO PARTICIPATE IN THE BREAKFAST/LUNCH PROGRAM, PLEASE SEND A BREAKFAST/LUNCH AND DRINK WITH YOUR CAMPER EACH DAY.
Meal Selection

CHEEKTOWAGA YOUTH & RECREATIONAL SERVICES

ZERO TOLERANCE/SPORTSMANSHIP POLICY

The Town of Cheektowaga Department of Youth & Recreational Services is dedicated to providing quality programs, services & opportunities in which all people can participate and enjoy. In order to provide a positive experience for our community, participants must abide by the following policies in order to maintain a courteous and professional atmosphere that reflects good sportsmanship/character at all times.

POLICY: Disruptive, unsportsmanlike and/or inappropriate behavior will not be tolerated. Such behavior includes, but is not limited to:

Harassment, ridiculing or intimidation of players, staff, other campers, coaches, officials or spectators by means of hostile, threatening /abusive behavior and/or verbal or written comments.

Physical contact/abuse, putting hands on others in an aggressive manner.

Defacing or damaging property.

Refusal to comply with lawful/reasonable requests from Department representatives.

PROCEDURE: Activities, games, events and any other Department related functions may be stopped when disruptive/inappropriate behavior is displayed. Violators will be identified and based upon the severity of the action, subject to a course of action that could include:

- Verbal warning
- Written warning
- Removal/suspension from program activity
- Prohibition from future programs, events, etc.
- Police intervention

In the event the violator is a parent/guardian/relative of a program participant, the participant may also be subject to any of the actions listed above.

Participants and/or parents or legal guardians will be required to sign a copy of this policy upon registration, although failure to obtain a signature shall not impair the binding nature of this policy.

In consideration of your accepting my or my child’s entry, I hereby, for myself, my child, my heirs, executors, and administrators, waiver and release any and all rights and claims for damages I or my child have against the Town of Cheektowaga Youth & Recreational Services Department and its representatives, successors and assigns for any and all injuries suffered by myself or my child on any activity sponsored by these groups.
Child's Name

First NameLast Name
Parent/Guardian Name

First NameLast Name
Signature - Zero Tolerance Policy
Date

MonthDayYear
Date

FINANCIAL AID APPLICATIONS (Cheektowaga Residents Only)
If you are interest in applying for financial aid please complete the prompts below. You will then reveive a call and/or email from the Community Development Office regarding the electronic application.
I intend to apply for financial aid (Cheektowaga Residents Only)
Parent/Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Camper's Name

First NameLast Name
Camper's Name

First NameLast Name
Camper's Name

First NameLast Name
Camper's Name

First NameLast Name
Should be Empty:

CAMP ALEXANDER - Crabapple

CAMPER DEMOGRAPHICS

Parents/Guardians (Also allowed to pick up camper)

EMERGENCY CONTACT (if above cannot be reached)

RELEASE PERMISSION

IMPORTANT:

CAMPER INFORMATION

REGISTRATION SELECTION

MEDICAL INFORMATION

PERMISSION FOR EMERGENCY MEDICAL ASSISTANCE

PERMISSION FOR FIELD TRIPS / SWIMMING / SUNSCREEN

MEDIA

WALKER/BIKER PERMISSION

FREE BREAKFAST & LUNCH PROGRAM INFORMATION

FINANCIAL AID APPLICATIONS (Cheektowaga Residents Only)