our Summer 2016 Camp Brochure

2016 MEDICAL HISTORY AND PERMISSION FORM
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Please complete all boxes and print legibly
All information is kept confidential
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All forms are due one week prior to camp attendance.
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CAMPER INFORMATION
Gender _________________
DOB (mm/dd /yyyy): _______ /_______ /_____________
Last Name: ____________________________________________
First Name: _____________________________________________
EMERGENCY CONTACT
Last Name: ___________________________________________
Relationship to Camper (circle):
Mother
Father
First Name: _____________________________________________
Guardian
Primary Phone: _______________________________________
Other (explain): _______________________________
Secondary Phone: _______________________________________
HEALTH INSURANCE INFORMATION
Insurance Carrier: ______________________________
Policy Number: _________________________________
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MEDICAL INFORMATION
Medical information for your camper must be updated and submitted to the Nature Center every calendar year. All medications must be
in the original container with the accurate pharmacy label and must be accompanied by a physician’s orders. Medications,
whether over-the-counter or prescription, should be turned into the Camp Director on the first day of camp each week. Children must be
able to self-administer all medications.
Medications and Dosage: ___________________________________________________________________________________________
Food/Drug Allergies or Dietary Restrictions: ___________________________________________________________________________
Medical Conditions or Physical Restrictions: ___________________________________________________________________________
Other Information We Should Know? : ________________________________________________________________________________
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AUTHORIZATION
I give my permission for (camper name) _________________________ to attend and participate in activities during his/her Cayuga
Nature Center program and particularly, but not limited to, the activities of swimming, TEAM Challenge Course, and the handling of
animals. I give permission for my child to administer sunscreen and/or bugspray and understand that if he/she is not able to, a staff
member may assist in application. I also understand that in the case of illness or injury, the primary contact and emergency contact will be
notified immediately. If emergency treatment is necessary, I understand that the participant will be transported to the nearest hospital
emergency room. I give my permission for the attending physician to give emergency treatment, including but not limited to anesthesia,
injections, and x-rays if necessary. I understand that the Cayuga Nature Center does not provide accidental or medical insurance and that
I am required to provide insurance for the camper. I hereby agree that I am financially responsible for such expenses.
Parent/Guardian Signature: ___________________________________ Date: _______________
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Please attach a copy of your insurance card and current immunization
records for your camper and return by mail or fax to (607) 273 – 1719
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1420 Taughannock Blvd
Ithaca, NY 14850
Phone: (607) 273 – 6260
2015 FINANCIAL POLICY AND PHOTO RELEASE FORM
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Please complete all boxes and print legibly
All information is kept confidential
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All forms are due one week prior to camp attendance.
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FINANCIAL POLICIES
Any questions or concerns regarding our financial policies and procedures can be directed to Michael Lucas, Director of Finance. You
can reach his office at (607) 273 – 6623 ext. 23
Payment Policy
A non – refundable deposit of $100.00 is due at time of registration to hold your camper’s space within the program. Your enrollment is
not finalized and space within the program is not guaranteed until a deposit is received. Full payment is due 3 weeks prior to your
campers first day of attendance. If payment is not received, your camper will be un-enrolled from the program and the deposit retained by
the Cayuga Nature Center.
Participant Cancellation Policy
If you must cancel enrollment for any reason our refund policy is as follows:
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If you cancel 22 or more days prior to the start date of the week you are canceling enrollment for, you are entitled to a full refund.
If you cancel 8 – 22 days prior to the start date of the week you are canceling enrollment for, the Nature Center will retain half
the full payment for the program.
3. If you cancel within 8 days of the start date of the week you are cancelling enrollment for, or after the program has begun, there
will be no refunds.
Late Pick - up Policy
Please be respectful of our staff and their assigned work hours. If your child remains in our care beyond the appointed pick – up time, the
Cayuga Nature Center reserves the right to charge you for the additional supervision costs incurred. The cost is $5 for each five minute
increment or portion thereof.
By signing below, I verify that I have read and understood all financial policies set forth by the Cayuga Nature Center, agree to the
policies stated above, and give my consent to be charged accordingly.
Parent/Guardian Signature: ___________________________________ Date: _______________
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PHOTO RELEASE
*Please check or initial one of the options below*
______ By checking on the adjacent line, I consent to and authorize the use and reproduction by Cayuga Nature Center, or anyone
authorized by the Cayuga Nature Center, of photographs taken of me/or my camper for any purpose without compensation to me. All
photographs are owned by Cayuga Nature Center. Cayuga Nature Center reserves the right to use these photographs in any of its print
and electronic publications for purposes of marketing, media, or retail.
______ By checking on the adjacent line, I withhold consent and do not authorize the use and reproduction by Cayuga Nature Center,
or anyone authorized by the Cayuga Nature Center, of photographs taken of me/or my camper for any purpose without compensation to
me.
Parent/Guardian Signature: ___________________________________ Date: ____________
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Please attach a copy of your insurance card and current immunization
records for your camper and return by mail or fax to (607) 273 – 1719
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1420 Taughannock Blvd
Ithaca, NY 14850
Phone: (607) 273 – 6260