Registration Form - Cary Academy
Registration Form - Cary Academy
Registration Form - Cary Academy
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
<strong>Cary</strong> <strong>Academy</strong> Summer Quest<br />
<strong>Registration</strong> <strong>Form</strong><br />
<strong>Cary</strong> <strong>Academy</strong> Summer Quest is now accepting online registration.<br />
Visit www.caryacademy.org/summer to register today!<br />
If you register online you do not need to fill out this form.<br />
SECTION 1: CAMPER’S INFORMATION<br />
Camper’s Name: _______________________________ __________________________ _________________________<br />
(First) (Last) (Nickname)<br />
Street Address: ________________________________________________________________________________________<br />
City: _____________________________________ State: ______________ Zip: __________ Home # (____)______________<br />
Birth Date: (M/D/YEAR) ____/____/______ Age_____ Male Female<br />
Grade Entering in Fall ‘13: ______ Present School ________________________ Preferred Email __________________________<br />
T-shirt Size: (100% cotton) Youth: YM (10-12) YL (14-16) Adult: AS AM AL AXL AXXL<br />
How did you hear about Summer Quest programs? _____________________________________________________________<br />
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<br />
you like to receive these program announcements? Yes No (If no box is selected, you will automatically be added to the list.)<br />
SECTION 2: FAMILY INFORMATION<br />
Mother/Guardian’s Name: ____________________________________________ Employer _____________________________<br />
Home Address: ______________________________________________ City: ____________________ State: _____ Zip ______<br />
Home # (___)_______________Work # (___)____________________ Cell or Pager # (Circle) (___)___________________________<br />
Father/Guardian’s Name: _____________________________________ Employer ______________________________________<br />
Home Address: _____________________________________________ City: _____________________ State: _____ Zip _______<br />
Home # (___)_______________Work # (___)____________________ Cell or Pager # (Circle) (___)___________________________<br />
With whom does the Camper reside? Both Mother Father Guardian<br />
SECTION 3: RELEASE AUTHORIZATION<br />
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<br />
that individual.<br />
Name: ______________________________________________ Relationship: ___________________________________________<br />
Name: ______________________________________________ Relationship: ___________________________________________<br />
Name: ______________________________________________ Relationship: ___________________________________________<br />
SECTION 4: EMERGENCY CARE INFORMATION<br />
If neither parent nor guardian can be contacted, call:<br />
Name: ______________________________________________ Relationship :<br />
Work# (___)_________ Home#(___)__________ Cell # (__)___________<br />
Name: ______________________________________________ Relationship :<br />
Work# (___)__________ Home#(___)__________ Cell # (___)__________
SECTION 5: HEALTH INFORMATION<br />
(Some camps may require an additional Health History <strong>Form</strong> signed by a physician. This form will be mailed in your confirmation packet.)<br />
IF AFTER A CAMP HAS BEGUN IT BECOMES APPARENT THAT A PARENT OR GUARDIAN HAS NOT DISCLOSED SPECIFIC MEDICAL OR EMOTIONAL NEEDS THAT<br />
CANNOT BE ACCOMODATED, THE CAMPER MAY BE REMOVED FROM CURRENT OR FUTURE CAMPS THAT HE OR SHE MAY BE REGISTERED WITHOUT REFUND OF<br />
REGISTRATION FEES.<br />
Check all that apply: Headaches/Migraines Seizures/ Epilepsy Hearing Loss<br />
ADD On medication Concussion or Head Injury Diabetes Type ______ Insulin Vision Loss<br />
ADHD On medication Major Surgery or Illness Allergies Epi Pen (carries) Eyeglasses/contacts<br />
Emotional Problems Heat Stroke/ Exhaustion ___ Medications___ Food Sprains, Fractures, Dislocations<br />
Behavior Problems Asthma Inhaler (carries) ___ Insects___ Plants Date of Last tetanus shot ____<br />
Heart Disease/Defect Contagious Disease Immunizations are up to date Other<br />
Please give a detailed explanation for anything checked above and list of medications with dosage:<br />
SECTION 6: REGISTRATION<br />
You may mix and match programs to create a full day of camp.<br />
Code (see descriptions) Program Name Fee<br />
Extended Care Total (see selections below)<br />
TOTAL FEES DUE<br />
BEFORE AND AFTER CAMP CARE - Before, Lunch and After Care is offered for campers who are in rising grades 2 - 12.<br />
<strong>Cary</strong> <strong>Academy</strong> offers an extended care option to meet the needs of today’s working families. Extended care activities may include<br />
opportunities to play board games, read books or participate in arts and crafts and recreational activities in a supervised environment.<br />
The central location for drop-off and pick-up is in the Sports and Education Annex (SEA building).<br />
LUNCH CARE<br />
Lunch care is available for any camper who is registered for a morning and afternoon camp during the same week. All campers<br />
registered for full day camps are already registered for lunch care.<br />
Campers who attend a full day of camps should bring a bag lunch and beverage with a cooler pack. No refrigeration is available.<br />
Vending machines are available and stocked with juices, soft drinks and a variety of healthy snacks. Dining facilities will be supervised<br />
during lunch care.<br />
Dates<br />
Before Care<br />
8am - 9am<br />
Lunch Care<br />
Noon - 1pm<br />
After Care<br />
4pm - 6pm<br />
Weekly Fee<br />
June 17 – June 21 $30 Free $50<br />
June 24 - June 28 $30 Free $50<br />
July 8 - July 12 $30 Free $50<br />
July 15 - July 19 $30 Free $50<br />
July 22- July 26 $30 Free $50<br />
Enter Extended Care Total in above worksheet:
SECTION 7:<br />
PERMISSIONS AND WAIVERS<br />
FIELD TRIP PERMISSION<br />
As the undersigned parent or guardian, I grant permission for my child to leave the <strong>Cary</strong> <strong>Academy</strong> premises on authorized trips under the supervision of<br />
<strong>Cary</strong> <strong>Academy</strong> Summer Programs Staff. All campers will only be transported on official <strong>Cary</strong> <strong>Academy</strong> buses with certified drivers.<br />
RELEASE & INDEMNITY AGREEMENT<br />
I understand that participating in the program selected involves risk of injury. These risks include inclement weather, facility or equipment problems or<br />
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<br />
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<br />
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<br />
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<br />
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<br />
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<br />
of any kind from <strong>Cary</strong> <strong>Academy</strong>, its employees or its agents for injury, illness, or death resulting from this program. If I am registering a child for a<br />
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,<br />
and discharge any legal rights that I may assert on behalf of the child participation in the program. I also agree not to sue <strong>Cary</strong> <strong>Academy</strong>, its employees,<br />
or its agents and agree to indemnify <strong>Cary</strong> <strong>Academy</strong> for all claims, damages, losses, or expenses, including attorney’s fees, if a suit is filed concerning an<br />
injury, illness, or death to me or to my child resulting from participation in the program.<br />
I, the undersigned parent or guardian, understand that an emergency situation may arise where the delay of medical or surgical procedures could<br />
endanger the well-being of my child. I do hereby grant permission to the staff of <strong>Cary</strong> <strong>Academy</strong> Summer Programs to render judgment in my absence<br />
concerning medical assistance or hospital care in the event of an accident or illness. I understand that <strong>Cary</strong> <strong>Academy</strong> will not administer any<br />
medications to my child unless a medication release form has been provided.<br />
I HAVE READ ALL INFORMATION ON THIS REGISTRATION FORM AND AGREE, ON BEHALF OF MY CHILD AND MYSELF, THAT I UNDERSTAND AND WILL ABIDE<br />
BY ALL POLICIES. I AGREE TO INFORM MY CHILD OF ALL BEHAVIOR EXPECTATIONS WHILE ATTENDING CARY ACADEMY SUMMER PROGRAMS. I ALSO<br />
ACKNOWLEDGE THAT ALL INFORMATION IS CORRECT AND MY CHILD IS PHYSICALLY AND EMOTIONALLY CAPABLE OF POSITIVLY PARTICIPATING IN<br />
SPECIFIED CAMP ACTIVITIES. BY SIGNING BELOW, I ALSO GRANT CONSENT TO ALL PERMISSIONS AND AGREE TO ALL WAIVERS ON THIS REGISTRATION<br />
FORM AS NOTED.<br />
I hereby authorize and give full consent to <strong>Cary</strong> <strong>Academy</strong> to publish and copyright all photographs in which my child appears while enrolled as<br />
a student in the summer programs of <strong>Cary</strong> <strong>Academy</strong>. Children will not be identified by name in photo captions. I agree that <strong>Cary</strong> <strong>Academy</strong> may<br />
use, in whole or in part, photography, videos, written extractions, and voice recordings of student for the purpose of illustrations, publications<br />
and websites. Additionally, I agree that use of a photograph or photograph(s) does not constitute in any manner a waiver of <strong>Cary</strong> <strong>Academy</strong><br />
program policies, program, or rules, nor does the continued us constitute an agreement to continue the child’s enrollment in the summer<br />
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<br />
legal right to issue such consent.<br />
Print Name: Signed: Date:<br />
SECTION 8: GUIDELINES & PROCEDURES<br />
SUMMER PROGRAM GUIDELINES<br />
1. Campers are expected to abide by the behavior expectations; parents must review the guidelines with their child prior to the start of camp.<br />
2. Except when excused by the Summer Programs Director, all campers are expected to remain on campus with the program in which they are<br />
enrolled.<br />
3. All campers should come dressed in appropriate attire for the type of camp he/she is attending. Specifically, campers participating in sports<br />
camps should dress appropriately and bring proper equipment. Specific information will be mailed with your registration confirmation.<br />
4. <strong>Cary</strong> <strong>Academy</strong> is a tobacco-free campus and as such prohibits the use of and distribution of all tobacco products by employees, students, and<br />
visitors.<br />
5. Campers are not permitted to possess or use alcoholic beverages or illegal substances on or off school property. The possession of weapons<br />
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<br />
activity.<br />
6. Prior to registration, any special physical, emotional, psychological, or medication needs of your child must be identified and if necessary<br />
discussed with the Summer Programs Director.<br />
CAMPER BEHAVIOR EXPECTATIONS<br />
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<br />
camp experience. In order to provide such an experience, Summer Quest asks that all staff members use praise and positive reinforcement as an<br />
effective way of managing the behavior of each camper.<br />
Should a negative behavior issue arise, we will apply the following guidelines:<br />
• FIRST OCCURRENCE: A quiet, verbal reprimand<br />
• SECOND OCCURRENCE: Verbal warning to camper and a phone call to parent or guardian<br />
• THIRD OCCURRENCE: Written incident report will be given to the parent or guardian.<br />
• If the inappropriate behavior continues beyond the written warning, the camper will be asked to leave for the remainder of the camp with no<br />
refund of already collected fees.<br />
• If the offense is severe including, but not limited to, fighting, theft, vandalism, possession of weapons, alcohol, cigarettes, or illegal substances,<br />
inappropriate language, severe verbal threats, physical aggression, leaving the designated area without permission, or sexual misconduct, the<br />
camper will be IMMEDIATELY dismissed from the current camp and any other camp he or she is registered to attend, bypassing all steps<br />
above, and NO REFUND WILL BE GIVEN. THE ACTIONS TAKEN WILL BE AT THE DISCRETION OF THE AUXILIARY PROGRAMS<br />
DIRECTOR.<br />
• There will be no refunds if cancellation takes place after the program starts or if a camper is temporarily or permanently suspended from a<br />
program due to failure to follow program guidelines (see above).
STUDENT NAME:<br />
PAYMENT AND REGISTRATION FORMS<br />
All payments for camp registrations are to be made in full at the time of registration.<br />
Make checks payable to <strong>Cary</strong> <strong>Academy</strong>. The registration form and payment can be mailed to <strong>Cary</strong> <strong>Academy</strong> Summer Quest, 1500 North Harrison<br />
Avenue, <strong>Cary</strong>, 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<br />
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,<br />
additional information about Summer Quest will be sent to you.<br />
Online registration is available at www.caryacademy.org/summer. If you are registering online, please do not send in a<br />
duplicate copy of the registration form. <strong>Registration</strong> will be accepted until five days prior to the start date of each camp.<br />
TRANSFER POLICY<br />
All transfer requests must be submitted in writing and may be sent to the Summer Quest office via e-mail, fax or mail.<br />
After April 1, 2013, a transfer fee of $15 per camp will be charged to the customer.<br />
REFUND POLICY<br />
All refund requests must be submitted in writing and may be sent to the Summer Quest office via e-mail, fax or mail.<br />
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<br />
cancelled. Program fees are fully refundable when the program is cancelled by <strong>Cary</strong> <strong>Academy</strong>. Otherwise, program fees are refundable as follows:<br />
• Cancellations received in writing on or before April 1, 2013 will be entitled to a full refund less a $25 cancellation fee per program.<br />
• Cancellations received after April 1, 2013 will only be entitled to a refund (less the applicable cancellation fee per program) if the camper’s<br />
spot can be filled.<br />
SECTION 9:<br />
PAYMENT INFORMATION<br />
Check or Money Order (Please make check payable to <strong>Cary</strong> <strong>Academy</strong>.)<br />
Cash (Received by Summer Quest Staff only; please do not send through mail)<br />
Credit Card (Visa/Mastercard/Discover is accepted.)<br />
Fax (<strong>Registration</strong> forms that have credit card information and are signed can be faxed to a secure office at 919-677-8892.<br />
Credit card cannot be processed unless all information is filled out below.<br />
Credit Card Number _______ Exp. Security Code (*3 digit number on back of card)<br />
(Mo./Yr.)<br />
Name as listed on card<br />
I authorize <strong>Cary</strong> <strong>Academy</strong> to charge registration fees to my credit card account<br />
(Cardholders Signature)<br />
Date<br />
SQ USE ONLY: PAYMENT FORM: CASH_____; CHECK ________; CHECK #_____; CREDIT CARD: MC___ VISA___ DISCOVER___