extreme registration

Extreme Summer Camp 2016 Ages 11-13
Complete 1 Registration form per child
Camper’s Name_________________________________
Date of Birth: __________________ Age: _________________
Parent Name(s): _________________________________ Camper Lives With (custodial parent):_________________________________
Work Ph: _____________________ Cell Ph (mom): ________________________ Cell Ph (dad): _______________________
Address: _______________________________________
City: ______________________
Parent(s) Email: _________________________________
Campers School:_____________________________ T-Shirt Size:___________
How did you hear about us? Previous Camper
Date
June
20-24
June
27-July1
July
4-8
Camp Guide/Mailing
Camp/Ages/Registration #
Cupcake Wars/ 11-13/ CA0608ECW
Camp H2O / 11-13 / CA0608EH2O

Survivor / 11-13/ CA0608ES
Fashion Week / 11-13 / CA0608EFW
Pirates Cove / 11-13 / CA0708EPC
July
11-15
Musical Theater / 11-13 / CA0708EMT
Dodgeball / 11-13 / CA0608EDB
July
18-22
Extreme Rockwall / 11-13 / CA0708ERW
Amazing Race/ 11-13 / CA0608EAR
July
25-29
Myth Busters / 11-13 /CA0708EMB
Extreme Basketball / 11-13 / CA0708EBB
August
1-5
Restaurant Week / 11-13 / CA0708ERW
Volleyball/ 11-13/ CA0708EVB
August
8-12
Science Camp / 11-13/ CA0808ESC
August
15-19
Cake Boss / 11-13 / CA0808ECB
Art 101 / 11-13/ CA0808EA
August
22-26
Iron Chef /11-13/ CA0808EIC
Internet
Deposit/ Fee

Full Wk:$______
$45 Deposit
Full Wk:$______
$45 Deposit
Full Wk:$______
$45 Deposit
Full Wk:$______
$45 Deposit
Full Wk:$______
$45 Deposit
Full Wk:$______
$45 Deposit
Full Wk:$______
$45 Deposit
Full Wk:$______
$45 Deposit
Full Wk:$______
$45 Deposit
Full Wk:$______
$45 Deposit
State: _________ Zip: ______________
At the Kroc
Ext. Care
Other:____________
Fieldtrips*
$25 (week)
$7 (day)
$20
Get Air
June 23rd
$25 (week)
$7 (day)
$40
OMSI
June 30th
$25 (week)
$7 (day)
$20
Super Bounce
July 7th
$25 (week)
$7 (day)
$40
Bullwinkle's
July 14th
$25 (week)
$7 (day)
$40
Silver Creek
Falls
July 21
$25 (week)
$7 (day)
$20
Get Air
July 28
$25 (week)
$7 (day)
$40
Pacific City
August 4th
$25 (week)
$7 (day)
$40
Silver Creek
Falls
August 11th
$25 (week)
$7 (day)
$40
Total Fee:
ZOO
August 11th
$25 (week)
$7 (day)
*ADMIN. ONLY:
Early Registration ($10 off each camp if registered by May 1st.)
Member #: _________________________
Multiple Weeks ($5 off each camp - when purchasing 5weeks or more. Must pay in full for discount to apply)
Discounts Applied: _______________________________________
Total Program Cost $_____________________
Cancellation/Transfer Policy
Monetary refunds will not be issued unless a Day Camp session is cancelled by the Kroc Center or for extenuating circumstances such as death
in the family, illness, etc. All refunds require an approval through the Camp Programs Coordinator. If the program is cancelled by the Kroc
Center, you will be given a full credit or cash refund.
Withdrawal from a program or class 7 or more days prior to the start of camp session: results in a refund, minus a $35 nonrefundable deposits or
registration fees. Withdrawal from a program or class 6 days or less prior to the start of camp session: results in a credit on a Kroc Center Gift
Card, minus a $10 administrative fee per class per participant and the $35 non-refundable deposits or registration fees.
A refund request form must be completed within one week of cancellation. Refunds placed on gift cards are applicable towards any Kroc Center
Program or merchandise and are not redeemable for cash. Please see the current Program Guide for the full cancellation policy.
No credits or pro-rated credits will be issued for partial attendance at a camp or missed days of camp due to illness, behavior issues, or any other
reason. I have read, understood, and agree to the Kroc Center policies regarding payments, transfers, cancellations, and credits.
Signature:_____________________________________________ Date:____________________________
Consent for Pictures/Video
I irrevocably grant The Salvation Army, its agents or employees, full and unlimited right, to use any and all photographs of the participant
taken at any of The Salvation Army Ray & Joan Kroc Corps Community Center Day Camps for any lawful purpose, including in any advertising, publicity, display, publication or media, and I waive any and all claims against The Salvation Army arising out of such use.
I agree that the Salvation Army may use such photographs of my child with or without my name and for any lawful purpose, including (but not limited to such purposes as publicity, illustration, advertising, and web content . )
 YES
 NO
Authorization and Liability Waiver
Parent/Guardian is required to sign authorization and waiver below to acknowledge understanding and agreement of the content.
In condition of the participation of my child at the Salvation Army’s Fall/Winter/Spring Break Camp program at the Ray and Joan Kroc Corps
Community Center, I (on behalf of myself and my child) agree to the following:
(1) I have been advised of and understand the types of activities that my child will be participating in while at the Kroc Center. While
the Kroc Center will provide supervision and act responsibly to ensure the safety and well being of my child, I understand that it is
possible that by participating in these activities, my child may be hurt or injured or may suffer the damage or loss of property, and I
agree to assume that risk.
(2) My child may participate in swimming or other water activities under required supervision.
(3) I also agree that the safety of my child is a shared responsibility and that I will promptly advise employees/staff of any medical or
physical condition that may create a safety or health risk for my child or other persons at the Kroc Center.
(4) I agree on behalf of myself and my child to waive any claims that I or my child may have against Kroc Center, its agents,
employees and volunteers for any injuries or property damages suffered as a result of my child's participation in activities offered
during Fall/Winter/Spring Break Camp, except for losses caused by the gross negligence or willful misconduct of the Salvation Army.
(5)I am authorizing the Kroc Center to seek medical attention for my child if an emergency were to arise while the minor camper is
involved in these activities. In an emergency the Kroc Center has my permission to call an ambulance or transport my child to any
available physician or hospital at my expense to obtain medical treatment. In most emergencies, 911 is called and the child is
transported to the nearest hospital and treated by the on-call physician. The parent or guardian of the child is notified as soon as
possible. I understand that The Salvation Army Ray and Joan Kroc Corps Community Center is not responsible for medical expenses.
I assume full responsibility for, and risk of, bodily injury, death or property damage due to the negligence of Releasee’s or otherwise and
understand that by signing below, I am giving up the right to sue The Salvation Army.
Signature: _________________________________________ Print Name:______________________________________ Date:______________
Register in Person: The Ray & J oan Kr oc Cor ps Community Center
1865 Bill Frey Dr . Salem, OR 97301 503.798.4791
Register by Email/Fax: E-mail: rachel.field@usw.salvationarmy.org
Fax to: 503-798-4895
Register Online: https://www.kr ocsales.org/#/salem
Must fill out Registration For m to complete r egistr ation
SUMMER DAY CAMP 2016
Pick-Up Authorization & Health History Form
(Complete 1 per child)
EMERGENCY CONTACT & PICK-UP AUTHORIZATION
HEALTH HISTORY (continued)
We require at least 3 emergency contacts /adults authorized for
pick up other than parents listed on registration form.
The information provided below will assist our staff in
providing the best care for your child.
(Only those listed will be allowed to sign your camper out of camp.)
Check if applicable or allergic:
People AUTHORIZED to pick-up my camper :
Name:_____________________________________________
Relationship:______________ Ph: (________) ____________
Name:_____________________________________________
Relationship:_____________ Ph: (________) _____________
Name:_____________________________________________
Diabetes
Asthma
Carries Epi-Pen
Epilepsy
Penicillin
Insect Stings
Carries Inhaler
Behavioral Challenges
Other:
______________________________________________
______________________________________________
Operations/Serious Injuries/ Diseases/ Restrictions on
Physical Activity: ______________________________
______________________________________________
______________________________________________
Relationship:_____________ Ph: (________) _____________
People NOT AUTHORIZED to pick-up my camper :
INFORMATION REQUIRED BY STATE LAW
Name:_____________________________________________
Name:_____________________________________________
HEALTH HISTORY
ARE YOUR CHILD’S IMMUNIZATIONS UP TO DATE?
Yes
No
Date of last Tetanus Shot:__________________________
Signature Required for those who do not have
immunizations due to religious reasons:
Signature:__________________________ Date:_______
DIETARY RESTRICTIONS:___________________________
___________________________________________________
___________________________________________________
___________________________________________________
Name & Purpose of any Medication: _____________________
_______________________________________________________________
(for medications to be administered at camp fill out the
back side of this form)
Health Insurance: Yes No
Company:_____________________________________
Policy Number: _________________________________
Family Doctor:__________________________________
Doctor’s Phone: ( _____) _________________________
Doctor’s Address:_______________________________
Dental Provider:_________________________________
Dentist’s Phone: (______)_________________________
SWIMMING LEVEL
Please explain your camper’s current swimming ability/
level: _________________________________________
______________________________________________
______________________________________________
______________________________________________
All campers who cannot pass a swim test will be allowed to swim in the leisure pool only and may be
required to wear a coast guard approved life jacket
in the pool.
MEDICATION INFORMATION FORM
Medications must be dropped off & picked up each day by the parent or authorized
adult at the sign in/out table.
All Medications must be in their original prescription container with the child’s name printed on the
label, and placed in a plastic bag. Any medication not brought in the appropriate container may
prevent your child from participating in camp that day.
Camper’s Name_____________________________________________ Age: ____ Date: ____________
Please complete the following section as necessary. A coordinator may contact you for additional information.
Medication & Strength:___________________________________________ Dosage:_________________
Administration Instructions (time of day, etc): __________________________________________________
_______________________________________________________________________________________
Storage Instructions:______________________________ Quantity Sent to Camp:_____________________
Date Prescribed:_____________ Expiration Date:____________ Temporary:_______ Permanent:________
Reason for Medication:____________________________________________________________________
Possible Side Effects (i.e.: reactions to food, dehydration, stress, drowsiness, etc.): ____________________
_______________________________________________________________________________________
Which, if any, of the above side effects has your child experienced? To what extent?
_______________________________________________________________________________________
Other important information regarding medication: ______________________________________________
Expected consequence if medicine is not taken as directed: ________________________________________
Medication & Strength:___________________________________________ Dosage:________________
Administration Instructions (time of day, etc): __________________________________________________
_______________________________________________________________________________________
Storage Instructions:______________________________ Quantity Sent to Camp:_____________________
Date Prescribed:_____________ Expiration Date:____________ Temporary:_______ Permanent:________
Reason for Medication:____________________________________________________________________
Possible Side Effects (i.e.: reactions to food, dehydration, stress, drowsiness, etc.): ____________________
_______________________________________________________________________________________
Which, if any, of the above side effects has your child experienced? To what extent?
_______________________________________________________________________________________
Other important information regarding medication: ______________________________________________
Expected consequence if medicine is not taken as directed: ________________________________________
CAMPER PERMISSION-TO-CARRY
All medications are to be administered by a Camp Counselor, or other designated personnel. By filling out the information below, Parents may authorize campers to carry/administer their own medication in the case of those needed for
potentially life-threatening situations (e.g.: Epi-pens for anaphylactic reactions or inhalers).
Medication: ______________________ Dosage: __________________Time of administration: ___________________________
Name of Physician: ____________________________Phone Number: _______________________________________________
By signing below, the parent/ legal guardian acknowledges that the child has been instructed in the purpose of
and appropriate administration of this medication and all other pertinent information regarding the medication
and has authorized him or her to self-administer as necessary.
Last Name: ___________________________
Season/Session:________________________
INCLUSION IN-TAKE FORM
Camper Name: ______________________________ Nickname: ________________________
School:___________________________ Grade (in fall):________________
Directions: Carefully read and thoroughly complete each answer. Clearly print all responses. This form has been prepared to
provide accommodations and support for the Kroc Center Day Camp/After School Program campers and their families.
Ability Profile:
Describe your child’s level of ability:
_______________________________________________________________________________________
___________________________________________________________________________
Indicate which of the following camp activities you foresee your child needing assistance/
accommodations for in order to successfully participate:
Arts & crafts
Board games
Computers
Large Group games
Lunch/snacks
Traditional Sports
Swimming
Other____________
If known, please Describe the type of assistance requested:___________________________
____________________________________________________________________
____________________________________________________________________
List anything that upsets (stresses) your child such as loud noises, lots of people, or having to stop doing an
enjoyable activity. ________________________________________________________________________
_______________________________________________________________________________________
List techniques or “tools” that help your child calm down when stressed (example: speaking quietly, having
something to hold or “fidget” with, taking deep breaths). _________________________________________
_______________________________________________________________________________________
Please understand that poor choices (negative behavior) result in consequences. We anticipate all campers
will show safe, respectful and acceptable behavior. In the unlikely event your camper requires corrective actions; please tell us what you find to be most effective in correcting the behavior.
_______________________________________________________________________________________
_______________________________________________________________________________________
Parents, please read the BELOW expectations for EVERY camper with your child and sign acknowledging your understanding. (Additional age-appropriate group expectations are reviewed with camp counselors.)
1. Stay with the group at all times.
2. Keep hands and feet to oneself; choose to use hands and feet for helping; not hitting, punching
or kicking others or the property of others.
3. Listen to all instructions given by staff. (If a child needs alternative ways of receiving information and instructions, please be sure to indicate such needs on this form).
Parent Signature: ____________________________________________Date: __________________
Camper Signature: ____________________________________________Date: __________________
Welcome to the Kroc Center and the Kroc Center Climbing Wall!
It is our desire to see that everyone has a safe and enjoyable time while participating in this exciting activity.
While our staff is well-trained on supervising the rock wall and all the activities that the Kroc Center offers to
climbers, it is important that you understand the risks and responsibilities that climbing entails.
Climbing is an inherently dangerous sport and all rules and instructions must be followed to ensure your safety.
We have done everything possible to minimize this risk, but it is not possible to completely eliminate this risk.
Climbing on the rock wall is a dangerous activity that may lead to severe injury or even death. Through training
and safe use of climbing gear these risks are minimized but cannot be completely eliminated.
Inherent risks in climbing indoors include, but are not limited to:
- jolting, jarring, or otherwise moving suddenly, violently, and/or without warning while climbing or belaying;
- becoming entangled in your ropes or the ropes of others;
- equipment failure, including wall holds, ropes, anchors, or harnesses;
- falling off of the climbing wall or being fallen on or hit by other participants;
- impacting the ground and/or climbing wall;
- your failure or the failure of other participants to follow the climbing wall rules.
LIABILITY WAIVER
By signing this waiver, you are signifying that you understand and accept these risks, are willing to follow all climbing wall rules, and will always follow the instructions of the rock wall attendants. Your signature or the signature
of a parent or adult guardian also signifies that you agree to waive, on behalf of yourself, your minor child, your
estate, and your assigns, any claim for injury, up to and including death, or damage to property against The Salvation Army, its agents, employees, or volunteers that may result from your or your minor child’s participation in
the rock climbing activity.
Minor Participant:
I understand that I am giving up my right and the below named minor’s right to sue The Salvation Army, except
as to losses caused by the gross negligence or willful misconduct of The Salvation Army.
______________________________
Print Name of Minor
_____
Age
____________________________
Relationship to Minor
______________________________ ___________________________
Print Name of Parent or Adult Legal
Sign
Guardian over the age of eighteen (18)
______________________________
Contact Information (Phone)
________________
Date
________________________________________________
(Email)
Kroc Camps Field Trip
Permission Form
Deadline to Sign up for Field Trips will be the MONDAY before the trip takes place
Lunch and snack are included in cost of field trip admission.
Child/Camper’s Name: ____________________________________________________ Birthdate: ______________
(Last)
(First)
(MI)
Parent/Guardian’s Name(s): _________________________________________ Home Phone: __________________
P/G Cell Phone (a) _____________________________
Half Day Field Trips-8:00am-12:30pm ($20):
Get Air– June 23rd
Super Bounce– July 7th
Get Air– July 28th
*$40 to Enroll All Day. 8:00am-5:00pm*
P/G Cell Phone (b)_________________________________
Full Day Field Trips– 8:00am-5:00pm ($40):
OMSI-June 30th
Bullwinkle's– July 14th
Silver Creek Falls-July 21st
Pacific City Beach Trip– August 4th
Silver Creak Falls-August 11th
Portland Zoo– August 18th
In case of emergency contact:
Name: _________________________________
Daytime Phone: ___________________________
Relationship: ____________________________
Evening Phone: ___________________________
Allergies (including medications child can NOT take) / Special heath concerns:
_________________________________________________________________________________________
Permission to Participate & Liability Waiver
I represent and warrant that the Participant is in good health and of sufficient physical fitness to participate in the above
selected activity, and I do not know of any physical condition which would prevent the Participant’s participation, cause harm to the
Participant or cause harm to others.
I Hereby authorize the employees, volunteers, and agents of The Salvation Army to provide transportation for the Participant in a
motor vehicle owned, leased or rented by The Salvation Army, during the Participant’s participation in the Activity. I understand that
transportation in a motor vehicle places the Participant at risk for serious personal injury, including death, and loss. Initials:_______
In consideration for The Salvation Army providing transportation for the Participant, I agree on behalf of myself and on behalf of the
Participant, as well as our estates and assigns, to relieve The Salvation Army and its officers, directors, employees, volunteers, and
agents from any and all liability, including without limitation negligence, in connection with any injury, loss, or damage to person,
including death, or any injury, loss or damage to property in connection with Participant’s transportation to the maximum extent permitted by law. Initials:___________.
I understand that the Authorization & Liability Waiver information I signed on page two of the main Kroc Camp form also applies to
these activities and fieldtrips. Initials:__________
I understand that by signing this Participation and Authorization Waiver, I give up my right and the Participant’s right to sue the Salvation Army. I agree that if any provision or part of any provision or the application of such is held invalid, illegal, or unenforceable,
the validity of all other provisions in this Participation and Authorization Waiver shall remain unaffected
Parent/Guardian Printed Name______________________ Signature ______________________ Date_______