2018-2019 School Break Camp Form

CAMP FEES

Þ Enrollment Fee: $30. Non-refundable, one time, charge.

Þ Daily Fee: $30 per day

Þ Late Pickup Fee: $1 per child per minute after 6:05pm, daily, to be paid at pickup.

Masks will be required to be worn

*

I understand and agree to the above fees.

Signature of Guardian /s/ *

Date

Month Day Year

Only the Guardian/Parent having legal and primary custody of the minor participant may fill out and submit this Registration form.

Your Name *

First Name Last Name

No School Days:

Mon, Nov 2 Tues, Nov 3 Wed, Nov 4 Thur, Nov 5

Fri, Nov 6 Mon, Jan 18 Fri, Jan 22 Mon, Feb 15

Fri, March 12

Holiday Camp Days:

Wed, Dec 23 Mon, Dec 28 Tue, Dec 29 Wed, Dec 30

Thur, Dec 31

Spring Break Camp:

Mon, March 29 Tues, March 30 Wed, March 31 Thurs, April 1

Fri, April 2

Are you the primary legal guardian/parent of child? *

Yes No

Relationship to child: *

E-mail

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Number

Area Code Phone Number

Business Number

Area Code Phone Number

Cell Number

Area Code Phone Number

Other guardian information:

Primary Guardian Secondary Guardian Legal Guardian

Name *

First Name Last Name

E-mail

Address (if different than above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Number

Area Code Phone Number

Business Number

Area Code Phone Number

Cell Number

Area Code Phone Number

Child's Name: *

First Name Last Name

Birth Date *

Month Day Year

Child's Age (as of Nov 2, 2020) *

Child's Gender *

Male Female

DOES YOUR CHILD...

...have a physical condition or disability, which we should be aware of? *

No Yes

Explain:

...have activity restrictions? *

No Yes

Explain:

...have any allergies *

No Yes

List:

...take any medications? *

No Yes

List:

...have behavior situations that we should be aware of? *

No Yes

Explain:

Are there any special instructions due to divorce, seperations or restraining order? *

No Yes

Explain:

Please list person and their relationship to the child (other than guardians listed previously) authorized by you to pick up your child. We will not release your child to anyone that is not listed on this form. We will need written verification of any changes in plans for your child's transportation arrangements. Please list one person per line.
ONLY THE PRIMARY GUARDIAN may add people to the pickup.

1. Full Name

First Name Last Name

Relationship:

Phone Number

Area Code Phone Number

2. Full Name

First Name Last Name

Relationship:

Phone Number

Area Code Phone Number

3. Full Name

First Name Last Name

Relationship:

Phone Number

Area Code Phone Number

4. Full Name

First Name Last Name

Relationship:

Phone Number

Area Code Phone Number

Emergency Medical Consent:

This consent gives permission for medical care in parental absence and must be presented upon admission for treatment. Every effort will be made to notify the parent or guardian immediately in case of emergency, illness, or injury. In the event that the parent cannot be contacted or arrive at Camp in ample time, the child will be transported by Ambulance in an emergency situation . In a non-emergency situation the child will remain at Camp until a parent or guardian can arrive.

*

In the event that my child requires medical or surgical care while I am absent or unable to be reached, I hereby give my consent to medical or surgical treatment.

Signature of Guardian /s/ *

Date

Month Day Year

Insurance Company:

In case of an emergency and guardian can not be reached, notify: (someone other than yourself)

Emergency Contact Name

First Name Last Name

Home Phone:

Area Code Phone Number

Work/Cell Phone:

Area Code Phone Number

Name of child's physician:

Phone Number

Area Code Phone Number

Name of child's dentist:

Phone Number

Area Code Phone Number

WAIVER FOR PARTICIPANT BY GUARDIAN:

In consideration of your accepting my child's entry into Camp Summit, I hereby, for myself, my child, my heirs, executors and administrators, waive and release any and all rights and claims for damages I or my child may have against the City of Lee’s Summit, Missouri its successors and assigns, it's employees, agents, attorneys, elected/appointed officials and directors for any and all injuries suffered by myself or my child at any activity sponsored by these groups. I further understand the risks and dangerous situations attendant to the activity for which my child is entering. I understand that I am required to escort my child into the building and sign in and out my child daily. The City of Lee’s Summit, Missouri assumes no responsibility for injury or accident insurance for program participants. Please review your personal policy. I understand the discipline and suspension policy of Camp Summit. I also understand that my child may be suspended without notice for negative behavior.

Signature of Guardian /s/ *

Date

Month Day Year

*

I understand that the rules of the Camp are designed for the well being and safety of the children participating, and failure to comply with these rules may result in suspension from Day Camp activities.

Signature of Guardian /s/ *

Date

Month Day Year

*

I hereby give permission for camper listed below to attend all Day Camp field trips as part of the Lee's Summit Parks and Recreation '20-'21 School Break Camp.

Name of Camper *

Signature of Guardian /s/ *

Date

Month Day Year

FOR YOUR INFORMATION AND UNDERSTANDING

I understand that there will be NO prorating of fees for absences, suspensions, or scheduling, unless the child is absent for one (1) full camp week. A doctor’s note must be provided in order to receive the refund.

I understand that if LSPR receives notification that a check covering ANY Camp Summit expenses has been returned for insufficient funds, my child will be unable to attend camp until the total amount including the $20 Returned Check Fee is paid in full at City Hall (220 SE Green Street)

*

I understand and agree to the above rules and terms.

Signature of Guardian /s/ *

Date

Month Day Year

20-21 School Break Camp Online Form