Child Name
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First Name
Last Name
Register for week 1 (Chuck E Cheese / Bowlmor)
Register for week 2 (Oakland Zoo)
Register for week 3 (Steinhart Aquarium)
Register for week 4 (Exploratorium)
Register for week 5 (Funtropolis)
Register for week 6 (Legoland)
Register for week 7 (Angel Island)
Entering Grade
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K
1
2
3
4
5
6
7
8
high school
T-shirt size
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YS
YM
YL
YXL
AS
AM
AL
AXL
Parent / Guardian #1 Phone
*
(###)
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####
Parent / Guardian #1 E-mail
*
Parent / Guardian #2 Phone
*
(###)
###
####
Parent / Guardian #2 E-mail
*
Please provide an estimate of your child's health
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Excellent
Good
Fair
CKZ staff may provide or apply sunscreen for my child as needed
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Yes
No
Child Medical Plan Name
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Child Medical Plan Policy Number
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Child Medical Plan Phone Number
*
(###)
###
####
Child Dentist Name
*
Child Dentist Phone Number
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(###)
###
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Emergency Contact #1
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First Name
Last Name
Emergency Contact #1 Phone
*
(###)
###
####
Emergency Contact #2
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First Name
Last Name
Emergency Contact #2 Phone
*
(###)
###
####
Emergency Contact #3
First Name
Last Name
Emergency Contact #3 Phone
(###)
###
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NO REFUNDS: No payments of tuition or fees will be refunded for any reason DISCIPLINE POLICY: Campers are expected to follow the camp rules. If a camper exhibits unacceptable behavior, re-direction will be used. If the behavior continues a separation from other campers will occur. Continued misbehavior will result in a parent conference or expulsion from the program. All decisions made by the Camp Director or School Principal are final. If a camper misses a field trip or is asked to leave camp due to unacceptable behavior, the parent will be responsible for picking up the camper. We will not provide alternate care for those unable to participate in daily camp activities. There will be no refunds if a camper cannot participate for disciplinary reasons. PERMISSION TO PARTICIPATE IN FIELD TRIPS: I allow my camper to participate in camp-sponsored activities at locations other than the school site. I allow my camper to walk on field trips to locations close to the school site. Activities may include swimming, field trips, overnights, campouts, bike days, roller skate days, etc. Activities will be guided and supervised by Summer Camp employees. Bus Transportation, as applicable, will be provided by Santa Clara Union School Transportation or public transportation. PERMISSION TO VIEW FILMS: I allow my camper to watch films at Camp according to the following ratings: Grades K – 2 “G” Rated films; Grades 3 – 6 “PG” Rated films; Grades 7 & 8 “PG–13” Rated films. ABSENCES: I will notify Camp Staff by 8:30am, if camper will be absent from camp, please leave a message. COPIES OF REGISTRATION FORMS: I understand that camp registration form may be copied / distributed for offsite use. CAMPER BEHAVIOR: I understand and accept the following: My Camper agrees to abide by all Camp rules and regulations. Campers are not allowed to possess or use any tobacco or smoking materials, alcohol, or illegal drugs. Campers are not to possess or use firecrackers or explosives. Campers may not possess weapons of any kind. I am responsible for any expense incurred because of willful damage or destruction of property caused by my camper. Campers may not leave Camp property or established boundaries without the approval of Camp Staff. Continued inappropriate behavior, including threatening, swearing, disobedience, teasing, spitting, harassment, intimidation or other improper behavior at any time may result in immediate expulsion from Camp with no refund. SIGN IN/OUT PROCEDURES: I understand that I will be required to sign in and sign out my Camper each day. MEDICATION: All medications prescribed for my Camper will be kept under the control of the Camp Director. I will complete a Medication Form, provided by the school, for my Camper. My Camper may not possess medication of any kind while at Camp. TRANSPORTATION RESPONSIBILITY: I understand that I must promptly transport my Camper home, at my expense, in the event that my camper is expelled from Camp for behavioral or other reasons. CAMP DIRECTOR: The Camp Director shall determine what constitutes a violation of Camp rules and shall determine consequences of such violations. IMPORTANT: Provide additional details about dietary restrictions, allergies, operations, injuries, medications or conditions affecting camp participation such as bee sting allergies, peanut allergies or foods your camper may not eat. AUTHORIZATION TO PROVIDE MEDICAL & DENTAL CARE: I/We, the parent(s)/guardian(s) of the camper named above hereby authorize the administration of St. Clare School to consent to, and agree to pay for, on my/our behalf any emergency medical, dental, surgical, or hospital care, treatment, of diagnosis to be rendered to or for my/our Camper under the general or special supervision of a physician/surgeon or dentist pursuant to Section 6910 of the California Family Code and/or Section 1317 of the Health and Safety Code of California. It is expressly understood and agreed that an “emergency” shall be determined at the discretion of the administration of St. Clare Summer Day Camp. Reasonable attempts will first be made to contact me/us prior to contacting an emergency treatment organization. I/We understand that St. Clare Summer Day Camp is not legally obligated to make the above referenced consents for medical care. Therefore, in consideration for the above referenced arrangements, the undersigned hereby agree to release, discharge, indemnify and hold harmless The Roman Catholic Bishop of San Jose, a Corporation Sole, its constituent organizations, including, but not limited to St. Clare School and their officers, agents and employees, from any and all claims for personal injuries, property damages, or indebtedness for medical treatment expenses that my/our Camper may suffer as a result of this arrangement whether or not such injuries, damages, or indebtedness are caused by the negligence (whether active or passive) of any of the entities or individuals named or described above. AGREEMENT: I accept the Terms and Conditions of the Summer Day Camp. I grant Authorization to Provide Medical/Dental Care as described. I agree to pay all Summer Day Camp Tuition and Fees on time and in full, with no refunds for any reason. ********** BY TYPING MY (PARENT/GUARDIAN) NAME BELOW, I INDICATE AGREEMENT WITH THE ABOVE **********
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