Moose Camp Consent Form

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Child's Name *

Consenting Parent Name *

Primary Contact Number *

Secondary Contact Number *

Contact Email *

Weeks Requested *

Week 1 (July 8th - 12th)

Week 2 (July 15th - 19th)

Week 3 (22nd - 26th)

Required

Time Sessions Requested *

AM (9:00 - 12:00)

PM (12:30 - 4:30)

AM & PM (9:00 - 4:30)

I understand and Consent to the following: *

Pay for the summer sessions ahead of time. The latest that you will be able to pay for your child’s participation CAMP will be on JUNE 1st.

Payment may also be made via a check (The Town Of Shutesbury - in Memo Summer Program) brought to one of our staff members, OR via the schools unipay account.

To maintain the safety of all of our students, same-day drop-ins will not be allowed. This is to ensure that we have adequate staffing for the number of students each afternoon. *Drop ins can be requested at least one week in advance and this request is not guaranteed. Drop ins are only for students who are enrolled on at least one other week. The Drop in fee is an additional $50 per week.

The Program is First come First Serve after the initial sign up deadline of April 1st.

Please understand that absences cannot be reimbursed. The time-slot that you have signed up for has intentionally had coverage hired to meet the needs of the group size.

For late pickups, there will be a $5 fee for every 5 minutes late that the pickup occurs to accommodate staff who need to stay late.

Some small additional treats maybe be provided, however, parents must pack a snack for half day sessions or a full lunch and snack for full day sessions.

As safety is our number one priority, we will not tolerate any physical harm between our students. If there is an incident involving physical harm, it will require an immediate pickup. If an incident is repeated or severe it can result in dismissal from the program.

Students must stay with our team and respect designated break spots/ quiet spots. If they leave our team it will result in an immediate pickup.

Students must be potty trained to attend, If there are any accidents parents will be called and the student must immediately be picked up for care.

Required

Please List All Allergies *

Please List Any Helpful Medical Information *

By signing below, I consent to everything listed above, and grant my child permission to participate in Moose Camp 2024. *

If you have any questions or concerns please contact:

carras@shutesburyschool.org

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