HomeMy WebLinkAbout2020 Summer Camp Registration Form
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Summer Camps 2020
*Please sign your child up for only one elective per week.
Summer Camp K-6 2020
(AM / PM Play included in fee)
(13927) Week 1: (June 8 - 12)
To Greener Pastures
OR
(13928) Week 1: (June 8 - 12)
Delicious, Nutritious, &
Snackalicious!
(13929) Week 2: (June 15 - 19)
Field Hockey
OR
(13930) Week 2: (June 15 - 19)
Journey to the Year 3000
(13931) Week 3: (June 22 - 26)
Mind-Boggling Missions
OR
(13932) Week 3: (June 22 - 26)
Find Your Spotlight
(13933) Week 4: (June 29 - July 3)
Booming Business Bootcamp
OR
(13934) Week 4: (June 29 - July 3)
Extremely Eccentric Play
(13935) Week 5: (July 6 - 10)
Acute Architecture
OR
(13936) Week 5: (July 6 - 10)
Science Fair Frenzy
(13937) Week 6: (July 13 - 17)
Uncharted Wonders
OR
(13938) Week 6: (July 13 - 17)
Photographer's Eye
(13939) Week 7: (July 20 - 24)
School of Rock
OR
(13940) Week 7: (July 20 - 24)
Totally Tasty Treats
(13941) Week 8: (July 27 - 31)
Soccer
OR
(13942) Week 8: (July 27 - 31)
Jedi Training
(13943) Week 9: (Aug. 3 - 7)
Summer Camp Splashtacular!
Time
9am - 4pm
9am - 4pm
9am - 4pm
9am - 4pm
9am - 4pm
9am - 4pm
9am - 4pm
9am - 4pm
9am - 4pm
9am - 4pm
9am - 4pm
9am - 4pm
9am - 4pm
9am - 4pm
9am - 4pm
9am - 4pm
9am - 4pm
Resident
$190
$190
$190
$190
$190
$190
$190
$190
$190
$190
$190
$190
$190
$190
$190
$190
$190
Non-Resident*
$195
$195
$195
$195
$195
$195
$195
$195
$195
$195
$195
$195
$195
$195
$195
$195
$195
Fill in amount
here
Supervised play is available at no extra cost from 7:30 a.m.- 9 a.m. and 4- 5:30 p.m.
*A non-resident is any individual residing outside the corporate limits of Iowa City.
Total Due $________________
T-Shirt Total from previous page $________________
Grand Total (t-shirts plus camp fees) $________________
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Summer Camp 2020
Payment
Make Checks Payable to: Iowa City Recreation Division
Bring or mail Payment to:
Iowa City Recreation Division
220 S. Gilbert St.
Iowa City, IA 52240
Method of Payment
Cash _____ Check _____ Discover Card _____ Master Card _____ Visa _____
Credit Card Information
Credit Card #: _____________ - _____________ - _____________ - _____________
Expiration Date: ___________________________ CVC: ______________________
Authorized Signature: __________________________________________________________
Only residents of Iowa City may apply for discounts based on income. Inquire at the Recreation
Division office for further questions.
Receipt # ____________________ Clerk’s Initials _______________ Date Sent ___________
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Summer Camp 2020
Emergency Information
Child's Full Name:
____________________________________________________________________________
First Middle Last Nickname
____________________________________________________________________________
Grade to be completed in 2019/2020 Date of Birth
1. Parent/Guardian with whom the child resides:
Name: ________________________________ Relationship to Child: ____________________
Address: ___________________________________ Day Phone: _______________________
Employer: _________________________________ Evening Phone: _____________________
Name: ________________________________ Relationship to Child: ____________________
Address: __________________________________ Day Phone: ________________________
Employer: _________________________________ Evening Phone: _____________________
2. Persons to contact if parents are unavailable in cases of illness, injury, or emergency:
If reasonable attempts to contact parents or guardians are unsuccessful, staff will contact
individuals below to pick up your child.
Name: ________________________________ Relationship to Child: ____________________
Address: ___________________________________ Day Phone: _______________________
Employer: _________________________________ Evening Phone: _____________________
Name: ________________________________ Relationship to Child: ____________________
Address: __________________________________ Day Phone: ________________________
Employer: _________________________________ Evening Phone: _____________________
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3. List people here who will be picking your child up on a regular basis:
Name: ________________________________ Relationship to Child: ____________________
Address: ___________________________________ Day Phone: _______________________
Employer: _________________________________ Evening Phone: _____________________
Name: ________________________________ Relationship to Child: ____________________
Address: __________________________________ Day Phone: ________________________
Employer: _________________________________ Evening Phone: _____________________
Name: ________________________________ Relationship to Child: ____________________
Address: __________________________________ Day Phone: ________________________
Employer: _________________________________ Evening Phone: _____________________
4. Legal custody restraints/person(s) who may NOT pick up your child:
(You must provide us with a copy of the court order for any individuals you list here.)
1. Name: _____________________________ Relationship to Child: _________________
2. Name: _____________________________ Relationship to Child: _________________
X___________________________________________________________________________
Signature of Parent/Guardian/Custodian Date
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Summer Camp 2020
Health Care Information – To be completed by Parent/Legal Guardian/Legal Custodian
Child's Full Name:
____________________________________________________________________________
First Middle Last Nickname
_____________ _________________________ _________________________ ____________
Date of Birth School of Last Attendance City & State Date
1. Significant illnesses and surgeries child has had (give age at time):
____________________________________________________________________________
____________________________________________________________________________
2. Any special health-related needs of child (allergies, medications, injuries, mental, emotional,
or physical conditions, etc):
____________________________________________________________________________
____________________________________________________________________________
3. Is there any impairment of vision, hearing or speech which we should be aware of?
____________________________________________________________________________
____________________________________________________________________________
4. Is your child subject to any conditions which limit mental or physical activity?
____________________________________________________________________________
____________________________________________________________________________
5. Is your child subject to any conditions which may result in an emergency situation?
____________________________________________________________________________
____________________________________________________________________________
6. Any other special needs your child may have?
____________________________________________________________________________
Remember: Parents of children requiring special arrangements for attendance must
contact the Iowa City Recreation Division in advance. In most cases, a two weeks notice
is recommended. Insufficient notice may result in a delay of your child's participation.
Please make special requests in writing and direct them to: Joyce Carroll at joyce-carroll@iowa-
city.org or Raquishia Harrington at raquishia-harrington@iowa-city.org
7. Date of last physical_____________Dr.___________________________________________
8. Are immunizations up to date? Yes No If no, what is needed?
____________________________________________________________________________
For the safety of all camp children and staff, the Iowa City Recreation Division reserves
the right to require proof of school age physical and/or record of immunization. All
participants not enrolled in Iowa Public Schools the current school year must provide a
copy of a school age physical AND record of immunizations.
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Summer Camp 2020
Emergency Medical Consent
Child's Name:
__________________________________ _______________________ ________________
First/ Middle/ Last Nickname Birth Date
___________________________________________ _________________________________
Child's Doctor Phone Number
____________________________________________________________________________
Doctor's Address
Known Allergies:
____________________________________________________________________________
Present Medication:
____________________________________________________________________________
In the event that my child___________________________, requires medical and/or surgical
care while I am out of the city or unable to be reached, I hereby give my consent for medical
transport, medical and/or surgical care at the most available medical facility. I agree to pay all
costs and fees contingent on any emergency care and/or treatment for my child as secured or
authorized under this consent.
X____________________________________ X_____________________________________
Signature of Parent/Guardian/Custodian Signature of Parent/Guardian/Custodian
Consent for Sunscreen
I, ______________________________________, give consent to the City of Iowa City to
provide the following special service during programs sponsored by the Iowa City Recreation
Division: Application of sunscreen by participant's parent and/or guardian and/or sunscreen
provided by the City of Iowa City Recreation Division in the absence of participant provided
sunscreen.
The undersigned parent(s) and/or guardian(s) hereby acknowledge that this service is solely for
the convenience of the recipient, that such service will be provided by a person who is not a
health professional; nevertheless the undersigned agree to indemnify, defend and hold
harmless the City of Iowa City, its officers, agents, employees and Recreation Division staff from
any and all claims, damages, costs, charges, expenses and suits resulting from the giving or
failure to give sunscreen as provided above.
X___________________________________________ X _____________________________
Signature of Parent/Guardian/Custodian Date
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Summer Camp 2020
Travel Authorization
I give permission for my child, ______________________________________, to participate in
the Iowa City Recreation Program for which I have registered him/her. I give permission for my
child to leave the Robert A. Lee Community Recreation Center, area parks and/or the
Mercer/Scanlon Facility, on a daily basis, for the trips by bus, car, public transportation or foot to
parks or other program destinations. I understand some of these field trips may occur outside
the city limits of Iowa City. The Parks and Recreation Department will notify parents before each
trip outside city limits via hand-out and/or posted message.
Signature of Parent/Guardian________________________________ Date________________
Swimming Skills
Please describe your child's level of swimming skills. For instance: "non-swimmer"; "can float";
"strong swimmer"; "swims in deep water"; "comfortable in deep water"; "fearful of deep water".
____________________________________________________________________________
Photos
Please note that Summer Camp activities may, from time to time, be photographed for future
brochures, other promotional materials, or for group pictures. Due to the public nature of our
Summer Camp facilities we cannot be responsible for photographs made by the media or
others. We will, however, do our best to adjust according to your needs. Should you have any
such concerns, please contact the Iowa City Recreation Division in writing at the time of your
registration. Thank you.
Authorization to Leave Camp Alone
Complete this form if your child will be leaving camp alone. For example, some older children
may ride a bus each day or attend a sports practice after camp. My child, _______________has
permission to leave the Iowa City Parks & Recreation Department Summer Day Camp
by_________________________ on _____________ at ________________________ to
(i.e. walking, biking, bus) (time)
____________________________________________________________________________
(Destination)
I understand the Iowa City Parks & Recreation Department will not to be responsible after my
child leaves the program as authorized above.
X_____________________________________ _____________________________________
Signature of Parent/Guardian/Custodian Date