SUMMER DAY CAMP 2016 CAMPER REGISTRATION FORM
Incomplete forms will not be processed. Please print legibly and fill in ALL fields.
1. CAMPER INFORMATION Name (First) ¨ Female
(Last)
Preferred First Name
¨ Male
Birthday
Current Grade
Age
Address Street or PO Box City
State
Zip
Home Phone
Parent Work Phone
Parent/Guardian Name
Cell Phone
E-mail
School Name
T-Shirt Size (check one) ¨ Youth S ¨ Youth M ¨ Youth L ¨ Youth XL ¨ This is my child’s first experience with Day Camp
¨ Adult S
¨ Adult M
¨ Adult L
¨ Adult XL
Insurance Company Name Phone Number
Group/Policy #
Primary Physician
Phone Number
2. EMERGENCY CONTACT PLEASE NOTE: Emergency contact must be outside of household. Name (First) Home Phone
(Last) Work Phone
Relationship to Camper Cell Phone
3. ALLERGIES/MEDICATIONS
Allergic to: ¨ Penicillin ¨ Aspirin ¨ Bee/Ant Stings ¨ Other: Type of Reaction: Shot records current as per camper’s local school district: ¨ Yes ¨ No Medical Information: State law requires all medicine be given and kept by the camp health personnel. All medications must be in the original container or packaging and only have the necessary dosage for the week. Please attach an additional sheet of paper if needed. Please list medicine, dosage, and time to administer:
4. STATEMENT OF TREATMENT/MEDICAL RELEASE
In case of needed emergency medical treatment, I hereby give permission to the physicians selected by the Director of IDEA Camp RIO or his/ her designee to secure treatment for my child. I further authorize Valley Regional Medical Center and all other medical facilities providing treatment to release pertinent information to IDEA Public School staff for the purpose of parental/guardian notification. I recognize the natural risks of injury or disability inherent in my child’s participation in IDEA Camp RIO's recreation program, and hereby assume the risk of injury that could result from these activities not excluding waterfront, archery, riflery, and waterslides. I release IDEA Public Schools, IDEA Camp RIO and the employees and volunteers of all such entities from liability for injury to my child from participation in these and other programs. I give my permission for my child’s photo(s) to be utilized at the discretion of IDEA Camp RIO which includes their website. However, I understand no name will be used with the photographs. Signature of Parent/Guardian
5. CAMPER HEALTH
Full disclosure of the following information is requested in order for Camp RIO to offer the safest environment for your child. The information is used with discretion by our health personnel and, if deemed necessary, by the staff members working directly with your child. Any medical or behavioral conditions requiring special conditions/personnel/knowledge, must be discussed personally with the Director prior to registration.
Suggestions from parents:
My child does NOT have permission to take the following over-the-counter medicines by direction of the camp’s designated health personnel. ¨ Tylenol/Acetaminophen ¨ Advil/Ibuprofen ¨ Sudafed/Decongestant ¨ Benadryl/Antihistamine ¨ Pepto Bismol ¨ Tums/Antacid ¨ Robitussin/Expectorant ¨ Swimmer’s Ear Solution
Behavioral Information: ¨ ADD ¨ ADHD ¨ Mild ¨ Acute ¨
On medication: Name:___________________ ¨ Off medication for summer
Emotional Information: ¨ Bi-Polar ¨ Homesickness ¨ Depression ¨ Mood Disorder ¨ Other (please describe) ___________________________________ Please tell us anything that might be helpful in working with your camper during day camp:
6. CAMP CHOICE PLEASE INDICATE FIRST AND SECTION CHOICE
Please note: All camps are day camps. Students will be bused from various locations in the Valley and will attend camp from 8am-4pm Monday through Thursday. Breakfast and lunch will be provided.
CAMP
GRADE
DATE
FEE
¨ RIO 1
2-5
June 13-16
$275
Wildlife photography is not available this session.
¨ RIO 2
2-5
June 20-23
$275
¨ Check box if your child (5th and 6th grade only) would like to take photography (free)
¨ RIO 3
2-5
June 27-30
$275
¨ Check box if your child (5th and 6th grade only) would like to take photography (free)
***Camp choice should be for the grade the camper IS CURRENTLY IN.
7. PAYMENT OPTIONS
Early Bird receives $25 OFF registration if registered and paid in full by April 30th.
Camp Session Amount
$
Early Bird Discount
$
Send a kid to camp donation
$
TOTAL DUE:
$
PAYMENT PLAN: $75.00 deposit is due before April 30th with the remaining balance due on May 15th. Credit cards will automatically be charged unless Camp RIO is notified. PAYMENT TYPES:
¨ Cash
$
¨ Personal Check (made to IDEA Public Schools)
$
¨ Credit Card
$
*VISA, Mastercard accepted
CREDIT CARD INFORMATION:
Name on Card: CSV#
Account # (Located on the back of your CC)
Expiration Date
Billing Statement Address w/ zip code:
Signature
IDEA CAMP RIO 280 Fish Hatchery Rd. Brownsville, TX 78520 • MAIN 956.678.6508 • 956.678.6509 You will receive confirmation within 10 business days of receipt. Please add
[email protected] to your email address book to ensure electronic delivery.
