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HomeMy WebLinkAbout2020 Summer Camp Registration Form 2 3 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) $________________ 4 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 ___________ 5 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: _____________________ 6 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 7 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. 8 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 9 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