2014 Boon Church VBS Child Registration Form

Boon Church AGAPE Summer Day Camp

519$25

Dear Parents, Greetings to you all. Summer vacation is almost here and AGAPE Summer Day Camp is open for enrollment. Register before May 19th and receive a $25 discount for each child registered. Spaces are limited. Register today!

201477815 201477822 43-72 Bowne Street, Flushing, NY 11355 (718)445-7640 Ext. 0 (718)445-5323

Age: Kindergarten to 8th GradeDate: 7/7-8/15, 2014 (6 Week Session 7/8-8/22, 2014 (7 Week SessionTime: 9AM to 5PM, Monday to FridaySite: Boon Church 43-72 Bowne Street, Flushing, NY 11355Contact: (718)445-7640 Ext. 0 (718)445-5323 faxField Trips: Bowling, Zoo, Hall of Science, AMNH, FunStation USA

/Camp Fees

1st Child2nd Child Discount

/ 6 Week Session / 7 Week Session

5/19Before 5/19

5/19After 5/19

5/19Before 5/19

5/19After 5/19

$655* $630*

$680*

$675*

$700*

$655*

$650*

$675*

1st Child

2nd Child Discount

$725* $700*

$750*

$755*

$780*

$725*

$730*

$755*

K to 5th

6th to 8th

Registration Information:1. Each student must have a registration form lled and signed by his/her parent.2. USDA Camp fee includes daily lunch and snack, except on eld trip days. Lunch provided by USDA School Food. 3. $100Camp Fee does not include $100 eld trip fee. 4. Students must pack their own lunch on trip days. If not going on trips, students are required to stay home that day. There will be no childcare on site. 5. 2nd Child Discounts are good for children within the same family who are registering on the same day. 6. Physical examination forms must be submitted at the time of registration. 7. 15$10 All students must be picked up in a timely manner. After 5:10pm, a late fee of $10/15 minutes will be administered. 8. Kindergarten students: please bring nap mat, blanket and pillow.9. Students who do not follow the camp rules, or are unable to adapt to classes, will be dismissed. Fees will be refunded according to the refund policy. 10. 13Refunds after camp opens are prorated based on the total weeks registered and attended. No refund on or after 7/13/2014. Trip Fee is not refundable.11. $30Any bounced checks will be charged a $30 fee.

*$100T

Plus $100 Field Trip Fee (Includes T-shirt, cap, backpack and all bus & admissions fee)

AGAPE Summer Day Camp Registration Form

/ Check Payable to:BOON CHURCH OF O.C.M.

Camp Fee: ____________

Trip Fee: $100

Siblings Camp Fee: ____________

Total: ____________

Child Name Grade in Sept.

/ Parent/Guardian Name

Street Address

Email

Pediatrician

Allergies Allergy Information:

Lunch Option

Pediatricians Phone Number

Apt # City State Zip Code

Phone Relationship to Child

Emergency Contact (1) Phone Relationship to Child

Emergency Contact (2) Phone Relationship to Child

Age Birth date Male

No Yes

Walk to School

In case of an emergency during camp hours, your child will be sent to the nearest hospital.

Stay in and bring lunch from home

T Camp T-shirt size ( check one)Youth XS Youth S Youth M Youth L Youth XL

Adult S Adult M Adult L Adult XL

Religion Christian

6 Weeks 7 Weeks

Buddhist Catholic

Muslim Other:

How did you hear about us? Attended Last Year After school Program

Chinese School Sunday School Newspaper

Other:

Female / /

I , _______________________ (Parents Name ), do hereby grant permission for ____________________ (Students Name ), to attend Boon Church of OCM Agape Summer Day Camp. I take full responsibility for anything that may happen to my child. I hereby absolve Boon Church of OCM of any legal responsibility. I agree and accept all the regulations provided by Boon Church

of OCM Agape Summer Day Camp.

Parent or Guardian Signature Date

OFFICE USE ONLY

Date Received

Received By

Cash Amount Check # Check Amount

/ /

Health Form

System Input

Consent Form Dismissal Form

This camp is licensed by the New York City Department of Health and Mental Hygiene and is inspectedtwice yearly. The inspection reports are led at the Bureau of Food Safety and Community Sanitation.

Trip Itinerary & Parental Consent Form For Off-Site and Swim Trips

Bureau of Child Care

Rev. 12/18/2013

Camp Name: __________________________________________ Session #: ______ CAMIS/RECORD ID#:____________________ Camp Address:___________________________________________________,____________________________,_______________

(Building Address) (Borough) (Zip code)

*If swim trip is not an all-day event, provide hours **If camp uses public transportation, indicate

Trip Date & (Swim Hours)*

Trip Destination & Complete Address Mode of

Transportation** Activities

Parental Consent

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Parental Consent:

I, _____________________________________, the parent/legal guardian of _____________________________________, (Parent Name) (Camper Name)

__________ hereby give permission for him/her to participate in the trips and activities as indicated on the above itinerary. (Camper Age)

Signature: ____________________________________________________ Date: _____________________

Use additional pages as needed.

michelleleungTypewritten Text


michelleleungTypewritten TextAGAPE SUMMER DAY CAMP40491136



michelleleungTypewritten Text7/17/2014 NY Hall of Science. 47-01 111th St., Corona, NY Yellow Bus Science Exploration



michelleleungTypewritten Text7/23/2014 Bronx Zoo. 2300 Southern Blvd, Bronx, NY 10460 Yellow Bus Wildlife Exploration

michelleleungTypewritten Text43-72 BOWNE STREETQUEENS11355

michelleleungTypewritten Text7/31/2014 American Museum of Natural History. Central Park W/79th St, NY Yellow Bus History




michelleleungTypewritten Text8/07/2014 Fun Station USA, 40 Rocklyn Avenue, Lynbrook, NY 11563 Yellow Bus Indoor Play

michelleleungTypewritten Text8/14/2014 Jib Lane. 67-19 Parsons Blvd, Flushing, NY 11365 Yellow Bus Bowling







Dismissal Form Name of Child ______________________________________ Grade in Sept. ______________________ We require that all children be picked up in a timely manner. A late fee of $10/15 minutes will be administered after 5:10pm. For the safety of your child, we will not release your child to any person(s) whom we do not have written permission to pick up your child. 15$10 At the end of each day, my child will return home by: ____ Walking Home ____ Being Picked Up The following people are authorized to pick up my child. Please fill in full name. 1. ________________________________________________________ Relationship to Child : _________________________ 2. ________________________________________________________ Relationship to Child : _________________________ 3. ________________________________________________________ Relationship to Child : _________________________ 4. ________________________________________________________ Relationship to Child : _________________________ 5. ________________________________________________________ Relationship to Child : _________________________ I, ___________________________________________, give the above people authorization to pick up my child from Boon Church of OCM. I and the participant who hold Boon Church, employees, and representatives harmless and assume all liability for any and all personal injury, bodily injury occurs as a result of my child traveling home. Signature: ______________________________________________ Relationship to Child : _________________________ Print: ___________________________________________________ Date _________________________

Boon Church 2014 AGAPE Summer Day Camp

Photographing and Videotaping Consent Childs name: _______________________________ I hereby give consent to Boon Church 2014 Summer Day Camp the right to photograph and videotape Camp activities with my child in the pictures. I understand the pictures are property of the Camp and will be used in the future solely for purposes of reporting and/or promoting Camp activities.

Parent/Guardian: _____________________________ (Print Name)

_____________________________

(Sign Name)

__________________ Date Signed

Health Care Provider Name and Degree (print) Provider License No. and State

Facility Name National Provider Identifier (NPI)

Address City State Zip

CHILD & ADOLESCENT HEALTH EXAMINATION FORMNYC DEPARTMENT OF HEALTH & MENTAL HYGIENE DEPARTMENT OF EDUCATION

TO BE COMPLETED BY PARENT OR GUARDIAN

Please Print Clearly

Press HardSTUDENT ID NUMBER

OSIS

Childs Last Name First Name Middle Name Sex 0 Female Date of Birth (Month/Day/Year )

Childs Address Hispanic/Latino?0 Yes 0 No

0 Male / /

Race (Check ALL that apply) 0 American Indian 0 Asian 0 Black 0 White0 Native Hawaiian/Pacific Islander 0 Other

City/Borough State Zip Code School/Center/Camp Name DistrictNumber

Phone NumbersHome

Health insurance 0 Yes(including Medicaid)? 0 No

0 Parent/Guardian Last Name First Name0 Foster Parent

Cell

Work

TO BE COMPLETED BY HEALTH CARE PROVIDER If yes to any item, please explain (attach addendum, if needed)Birth history (age 0-6 yrs)

0 Uncomplicated 0 Premature: weeks gestation

Does the child/adolescent have a past or present medical history of the following?0 Asthma (check severity and attach MAF/Asthma Action Plan): 0 Intermittent 0 Mild Persistent 0 Moderate Persistent 0 Severe Persistent

If persistent, check all current medication(s): 0 Inhaled corticosteriod 0 Other controller 0 Quick relief med 0 Oral steroid 0 None0 Complicated by 0 Attention Deficit Hyperactivity Disorder 0 Orthopedic injury/disability Medications (attach MAF if in-school medication needed)Allergies 0 None 0 Epi pen prescribed

0 Drugs (list)

0 Foods (list)

0 Other (list)

0 Chronic or recurrent otitis media 0 Seizure disorder0 Congenital or acquired heart disorder 0 Speech, hearing, or visual impairment0 Developmental/learning problem 0 Tuberculosis (latent infection or disease)0 Diabetes (attach MAF) 0 Other (specify)

0 None 0 Yes (list below)

Dietary Restrictions0 None 0 Yes (list below)

PHYSICAL EXAMINATION

Height cm ( %ile)

Weight kg ( %ile)

BMI kg/m2 ( %ile)

Head Circumference (age 2 yrs) cm ( %ile)

Blood Pressure (age 3 yrs) /

Explain all checked items above or on addendum

General Appearance:Nl Abnl Nl Abnl Nl Abnl Nl Abnl Nl Abnl0 0 HEENT 0 0 Lymph nodes 0 0 Abdomen 0 0 Skin 0 0 Psychosocial Development0 0 Dental 0 0 Lungs 0 0 Genitourinary 0 0 Neurological 0 0 Language0 0 Neck 0 0 Cardiovascular 0 0 Extremities 0 0 Back/spine 0 0 Behavioral

Describe abnormalities:

DEVELOPMENTAL (age 0-6 yrs) 0 Within normal limits SCREENING TESTS Date Done Results Date Done Results

If delay suspected, specify below Blood Lead Level (BLL)(required at age 1 yr and 2 yrs

/ / g/dL Tuberculosis Only required for students entering intermediate/middle/junior or high school who have not previously attended any NYC public or private school0 Cognitive (e.g., play skills) and for those at risk) / / g/dL

PPD/Mantoux placed / / Induration mmLead Risk Assessment 0 At risk (do BLL) PPD/Mantoux read / / 0 Neg 0 Pos

0 Communication/Language (annually, age 6 mo-6 yrs)

Hearing

/ / 0 Not at riskInterferon Test / / 0 Neg 0 Pos

0 Social/Emotional 0 Pure tone audiometry 0 Normal 0 OAE / / 0 Abnormal Chest x-ray 0 Nl 0 Not

0 Adaptive/Self-Help

Hemoglobin or Head Start Only

g/dL

(if PPD or Interferon positive)

Vision

/ / 0 Abnl Indicated

Acuity Right / 0 Motor Hematocrit (age 912 mo) (required for new school entrants / / Left /

IMMUNIZATIONS DATES CIR Number

/ / % and children age 47 yrs) 0 with glasses Strabismus 0 No 0 Yes

of Child Influenza / / / / / / Hep B / / / / / / / / MMR / / / / / / Rotavirus / / / / / / Varicella / / / / DTP/DTaP/DT / / / / / / Td / / / / / /

/ / / / / / Tdap / / Hep A / / / / Hib / / / / / / / / Meningococcal / / / / PCV / / / / / / / / HPV / / / / / / Polio / / / / / / / / Other, specify: / / ; / /

RECOMMENDATIONS 0 Full physical activity 0 Full diet

0 Restrictions (specify)

Follow-up Needed 0 No 0 Yes, for Appt. date: / /

Referral(s): 0 None 0 Early Intervention 0 Special Education 0 Dental 0 Vision

0 Other

ASSESSMENT 0 Well Child (V20.2) 0 Diagnoses/Problems (list) ICD-9 Code

Health Care Provider Signature Date DOHMH PROVIDER/ / ONLY I.D.

TYPE OF EXAM: NAE Current NAE Prior Year(s)Comments

Telephone Fax

DateReviewed:

/ /

I.D. NUMBER

( ) ( ) REVIEWER:

CH-205 (5/08) Copies: White School/Child Care/Early Intervention/Camp, Canary Health Care Provider, Pink Parent/Guardian

2008

N.Y.

Documents

2014 Boon Church VBS Child Registration Form