Registration Form - Cary Academy

caryacademy.org

Registration Form - Cary Academy

Cary Academy Summer Quest

Registration Form

Cary Academy Summer Quest is now accepting online registration.

Visit www.caryacademy.org/summer to register today!

If you register online you do not need to fill out this form.

SECTION 1: CAMPER’S INFORMATION

Camper’s Name: _______________________________ __________________________ _________________________

(First) (Last) (Nickname)

Street Address: ________________________________________________________________________________________

City: _____________________________________ State: ______________ Zip: __________ Home # (____)______________

Birth Date: (M/D/YEAR) ____/____/______ Age_____ Male Female

Grade Entering in Fall ‘13: ______ Present School ________________________ Preferred Email __________________________

T-shirt Size: (100% cotton) Youth: YM (10-12) YL (14-16) Adult: AS AM AL AXL AXXL

How did you hear about Summer Quest programs? _____________________________________________________________

Throughout the year, we e-mail parents about additional program offerings that are open to the public. If you are not a CA family, would

you like to receive these program announcements? Yes No (If no box is selected, you will automatically be added to the list.)

SECTION 2: FAMILY INFORMATION

Mother/Guardian’s Name: ____________________________________________ Employer _____________________________

Home Address: ______________________________________________ City: ____________________ State: _____ Zip ______

Home # (___)_______________Work # (___)____________________ Cell or Pager # (Circle) (___)___________________________

Father/Guardian’s Name: _____________________________________ Employer ______________________________________

Home Address: _____________________________________________ City: _____________________ State: _____ Zip _______

Home # (___)_______________Work # (___)____________________ Cell or Pager # (Circle) (___)___________________________

With whom does the Camper reside? Both Mother Father Guardian

SECTION 3: RELEASE AUTHORIZATION

This person(s) may be required to show proper Identification and must have a release form with parent signature for child to be released to

that individual.

Name: ______________________________________________ Relationship: ___________________________________________

Name: ______________________________________________ Relationship: ___________________________________________

Name: ______________________________________________ Relationship: ___________________________________________

SECTION 4: EMERGENCY CARE INFORMATION

If neither parent nor guardian can be contacted, call:

Name: ______________________________________________ Relationship :

Work# (___)_________ Home#(___)__________ Cell # (__)___________

Name: ______________________________________________ Relationship :

Work# (___)__________ Home#(___)__________ Cell # (___)__________


SECTION 5: HEALTH INFORMATION

(Some camps may require an additional Health History Form signed by a physician. This form will be mailed in your confirmation packet.)

IF AFTER A CAMP HAS BEGUN IT BECOMES APPARENT THAT A PARENT OR GUARDIAN HAS NOT DISCLOSED SPECIFIC MEDICAL OR EMOTIONAL NEEDS THAT

CANNOT BE ACCOMODATED, THE CAMPER MAY BE REMOVED FROM CURRENT OR FUTURE CAMPS THAT HE OR SHE MAY BE REGISTERED WITHOUT REFUND OF

REGISTRATION FEES.

Check all that apply: Headaches/Migraines Seizures/ Epilepsy Hearing Loss

ADD On medication Concussion or Head Injury Diabetes Type ______ Insulin Vision Loss

ADHD On medication Major Surgery or Illness Allergies Epi Pen (carries) Eyeglasses/contacts

Emotional Problems Heat Stroke/ Exhaustion ___ Medications___ Food Sprains, Fractures, Dislocations

Behavior Problems Asthma Inhaler (carries) ___ Insects___ Plants Date of Last tetanus shot ____

Heart Disease/Defect Contagious Disease Immunizations are up to date Other

Please give a detailed explanation for anything checked above and list of medications with dosage:

SECTION 6: REGISTRATION

You may mix and match programs to create a full day of camp.

Code (see descriptions) Program Name Fee

Extended Care Total (see selections below)

TOTAL FEES DUE

BEFORE AND AFTER CAMP CARE - Before, Lunch and After Care is offered for campers who are in rising grades 2 - 12.

Cary Academy offers an extended care option to meet the needs of today’s working families. Extended care activities may include

opportunities to play board games, read books or participate in arts and crafts and recreational activities in a supervised environment.

The central location for drop-off and pick-up is in the Sports and Education Annex (SEA building).

LUNCH CARE

Lunch care is available for any camper who is registered for a morning and afternoon camp during the same week. All campers

registered for full day camps are already registered for lunch care.

Campers who attend a full day of camps should bring a bag lunch and beverage with a cooler pack. No refrigeration is available.

Vending machines are available and stocked with juices, soft drinks and a variety of healthy snacks. Dining facilities will be supervised

during lunch care.

Dates

Before Care

8am - 9am

Lunch Care

Noon - 1pm

After Care

4pm - 6pm

Weekly Fee

June 17 – June 21 $30 Free $50

June 24 - June 28 $30 Free $50

July 8 - July 12 $30 Free $50

July 15 - July 19 $30 Free $50

July 22- July 26 $30 Free $50

Enter Extended Care Total in above worksheet:


SECTION 7:

PERMISSIONS AND WAIVERS

FIELD TRIP PERMISSION

As the undersigned parent or guardian, I grant permission for my child to leave the Cary Academy premises on authorized trips under the supervision of

Cary Academy Summer Programs Staff. All campers will only be transported on official Cary Academy buses with certified drivers.

RELEASE & INDEMNITY AGREEMENT

I understand that participating in the program selected involves risk of injury. These risks include inclement weather, facility or equipment problems or

failures, contacts with and actions of other participants, and physical injuries, among others. I choose for myself or for my child to participate in the

selected programs despite the risks. By signing this form, I acknowledge all risks of injury, illness, and death and affirm that I have assumed all

responsibility of injury, illness, or death in any way connected with participation in the program. I certify that there are no medical or other reasons why

my child should not participate in this program. I also agree for myself and for any child participant to follow all rules and procedures of the program and

to follow the reasonable instructions of the teachers and supervisors of the program. In return for the opportunity to participate in this program, I agree

for myself and for me heirs, assigns, executors, and administrators to release, waive and discharge any legal rights I may have to seek payment or relief

of any kind from Cary Academy, its employees or its agents for injury, illness, or death resulting from this program. If I am registering a child for a

program, I agree that I am a parent, legal guardian, or am otherwise responsible for the child whose application I am submitting and that I release waive,

and discharge any legal rights that I may assert on behalf of the child participation in the program. I also agree not to sue Cary Academy, its employees,

or its agents and agree to indemnify Cary Academy for all claims, damages, losses, or expenses, including attorney’s fees, if a suit is filed concerning an

injury, illness, or death to me or to my child resulting from participation in the program.

I, the undersigned parent or guardian, understand that an emergency situation may arise where the delay of medical or surgical procedures could

endanger the well-being of my child. I do hereby grant permission to the staff of Cary Academy Summer Programs to render judgment in my absence

concerning medical assistance or hospital care in the event of an accident or illness. I understand that Cary Academy will not administer any

medications to my child unless a medication release form has been provided.

I HAVE READ ALL INFORMATION ON THIS REGISTRATION FORM AND AGREE, ON BEHALF OF MY CHILD AND MYSELF, THAT I UNDERSTAND AND WILL ABIDE

BY ALL POLICIES. I AGREE TO INFORM MY CHILD OF ALL BEHAVIOR EXPECTATIONS WHILE ATTENDING CARY ACADEMY SUMMER PROGRAMS. I ALSO

ACKNOWLEDGE THAT ALL INFORMATION IS CORRECT AND MY CHILD IS PHYSICALLY AND EMOTIONALLY CAPABLE OF POSITIVLY PARTICIPATING IN

SPECIFIED CAMP ACTIVITIES. BY SIGNING BELOW, I ALSO GRANT CONSENT TO ALL PERMISSIONS AND AGREE TO ALL WAIVERS ON THIS REGISTRATION

FORM AS NOTED.

I hereby authorize and give full consent to Cary Academy to publish and copyright all photographs in which my child appears while enrolled as

a student in the summer programs of Cary Academy. Children will not be identified by name in photo captions. I agree that Cary Academy may

use, in whole or in part, photography, videos, written extractions, and voice recordings of student for the purpose of illustrations, publications

and websites. Additionally, I agree that use of a photograph or photograph(s) does not constitute in any manner a waiver of Cary Academy

program policies, program, or rules, nor does the continued us constitute an agreement to continue the child’s enrollment in the summer

program. I hereby approve the foregoing and consent to the use of photography subject to the terms mentioned above. I affirm that I have the

legal right to issue such consent.

Print Name: Signed: Date:

SECTION 8: GUIDELINES & PROCEDURES

SUMMER PROGRAM GUIDELINES

1. Campers are expected to abide by the behavior expectations; parents must review the guidelines with their child prior to the start of camp.

2. Except when excused by the Summer Programs Director, all campers are expected to remain on campus with the program in which they are

enrolled.

3. All campers should come dressed in appropriate attire for the type of camp he/she is attending. Specifically, campers participating in sports

camps should dress appropriately and bring proper equipment. Specific information will be mailed with your registration confirmation.

4. Cary Academy is a tobacco-free campus and as such prohibits the use of and distribution of all tobacco products by employees, students, and

visitors.

5. Campers are not permitted to possess or use alcoholic beverages or illegal substances on or off school property. The possession of weapons

or explosives of any kind, or objects, tools or devices that may be used as weapons is prohibited on campus and at any summer programrelated

activity.

6. Prior to registration, any special physical, emotional, psychological, or medication needs of your child must be identified and if necessary

discussed with the Summer Programs Director.

CAMPER BEHAVIOR EXPECTATIONS

One of the primary objectives of the Summer Quest staff is to provide a positive and safe environment that allows your child to have a fun and enriching

camp experience. In order to provide such an experience, Summer Quest asks that all staff members use praise and positive reinforcement as an

effective way of managing the behavior of each camper.

Should a negative behavior issue arise, we will apply the following guidelines:

• FIRST OCCURRENCE: A quiet, verbal reprimand

• SECOND OCCURRENCE: Verbal warning to camper and a phone call to parent or guardian

• THIRD OCCURRENCE: Written incident report will be given to the parent or guardian.

• If the inappropriate behavior continues beyond the written warning, the camper will be asked to leave for the remainder of the camp with no

refund of already collected fees.

• If the offense is severe including, but not limited to, fighting, theft, vandalism, possession of weapons, alcohol, cigarettes, or illegal substances,

inappropriate language, severe verbal threats, physical aggression, leaving the designated area without permission, or sexual misconduct, the

camper will be IMMEDIATELY dismissed from the current camp and any other camp he or she is registered to attend, bypassing all steps

above, and NO REFUND WILL BE GIVEN. THE ACTIONS TAKEN WILL BE AT THE DISCRETION OF THE AUXILIARY PROGRAMS

DIRECTOR.

• There will be no refunds if cancellation takes place after the program starts or if a camper is temporarily or permanently suspended from a

program due to failure to follow program guidelines (see above).


STUDENT NAME:

PAYMENT AND REGISTRATION FORMS

All payments for camp registrations are to be made in full at the time of registration.

Make checks payable to Cary Academy. The registration form and payment can be mailed to Cary Academy Summer Quest, 1500 North Harrison

Avenue, Cary, NC 27513. You may also drop off the form and payment at the reception desk in the Administration Building. If paying by credit card you

may fax this registration form to 919-677-8892. The fax machine is kept in a secure office within our Business Office. Upon receipt of full payment,

additional information about Summer Quest will be sent to you.

Online registration is available at www.caryacademy.org/summer. If you are registering online, please do not send in a

duplicate copy of the registration form. Registration will be accepted until five days prior to the start date of each camp.

TRANSFER POLICY

All transfer requests must be submitted in writing and may be sent to the Summer Quest office via e-mail, fax or mail.

After April 1, 2013, a transfer fee of $15 per camp will be charged to the customer.

REFUND POLICY

All refund requests must be submitted in writing and may be sent to the Summer Quest office via e-mail, fax or mail.

All summer programs require a minimum enrollment; you will be notified at least two weeks prior to the start date in the event a program must be

cancelled. Program fees are fully refundable when the program is cancelled by Cary Academy. Otherwise, program fees are refundable as follows:

• Cancellations received in writing on or before April 1, 2013 will be entitled to a full refund less a $25 cancellation fee per program.

• Cancellations received after April 1, 2013 will only be entitled to a refund (less the applicable cancellation fee per program) if the camper’s

spot can be filled.

SECTION 9:

PAYMENT INFORMATION

Check or Money Order (Please make check payable to Cary Academy.)

Cash (Received by Summer Quest Staff only; please do not send through mail)

Credit Card (Visa/Mastercard/Discover is accepted.)

Fax (Registration forms that have credit card information and are signed can be faxed to a secure office at 919-677-8892.

Credit card cannot be processed unless all information is filled out below.

Credit Card Number _______ Exp. Security Code (*3 digit number on back of card)

(Mo./Yr.)

Name as listed on card

I authorize Cary Academy to charge registration fees to my credit card account

(Cardholders Signature)

Date

SQ USE ONLY: PAYMENT FORM: CASH_____; CHECK ________; CHECK #_____; CREDIT CARD: MC___ VISA___ DISCOVER___

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