Summer Camp 2024

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Summer Camp 2024

Registration Form

Email *

Record my email address with my response

Summer Camp 2024

Name *

age *

Date of Birth *

Gender

Female

Male

Prefer not to say

Other:

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School

Grade *

Address *

Ethnicity

Hispanic

Non Hispanic

Clear selection

Race

American Indian

Asian

Black/African American

Pacific Islander

White

Other:

Clear selection

Child Uses

Free Lunch

Reduced Lunch

Other:

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Parent /Guardian Information

Employer *

Parent/Guardian name: *

Address *

Phone *

Work Phone *

Cell phone number

Email *

2 parent/Guardian Name: *

Marital status

Married

Divorced

Single

Widowed

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If divorced who has legal custody? * A court order is needed if parent is denied access to the child. *

I authorize the following people to pick up my child from the After school Program. All authorized persons MUST BE AT LEAST 16 years of age and be prepared to show PHOTO ID.

Medical Information

Allergies and Special Needs

Does your child have any allergies *

Yes

Please list allergies

Does your child take any medication? *

Yes

Please List Medications

Does Your child have any special needs? *

Yes

Required

Please Describe

Physician Information

Physician's name *

Office name *

Address of Office *

Phone Number

Fax Number

Please indicate if your child has a history of the following.

contact lenses

Fainting

Appendicitis

Anemia

diabetes

Hay Fever

Swimmer's ear

Skin Problems

Hyperkinesias

High blood pressure

Severe Headache

Tonsillitis

Asthma

Ear infections

Seizures

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Conditions of Acceptance

Conditions of Acceptance
1. I agree to return all Summer Camp enrollment forms to the Hamilton Hill Arts Center prior to my child(ren) starting Camp. Children may not participate in the After School Program until all forms are completed and on file with the Center.
2. I understand that any changes to my original registration must be submitted in writing.
3. I understand that the hours of operation for the Summer Camp are 10am -3 p.m. Children are to be picked up by 3:00pm for summer camp. *** A FEE of $1. per minute Will BE ADDED FOR LATE PICK UP STARTING AT 6PM
4. I understand that my child must comply with Summer Camp rules and standards of behavior. I agree that the Center’s Staff has the right to enforce appropriate standards of conduct and may dismiss a member who infringes on the rights of others.
5. I give my permission for the use of any photographs, slides or videotapes, which may contain my child, to be used in the Hamilton Hill Arts Center promotional materials as well as social media.
6. I give my permission for my child to be transported to and from ASP field trips and activities.

7. I certify that my child is capable of participating in Summer Camp activities. This means that They are able to practice Basic self care ,defined as:

The ability to go to the bathroom without assistance
The ability to eat without assistance
The ability to dress independently
The ability to clean themselves independently

In addition children must be able to:

Interact appropriately and safely with others
Explain what they need, and ask for help
Follow instructions.

8. I grant the Hamilton Hill Arts Center and it’s agents full authority to take whatever

action they deem necessary regarding my child’s health and safety and I fully release the Hamilton Hill Arts Center and it’s agents from any liability in connection with those decisions.

9. I understand that this is a Drop in Arts Center NOT a Day Care! All children are welcome provided they meet the conditions above. No confirmation is necessary, once we have received your forms, children can begin immediately Children can come as often or as little as they would like.

Child's Name

Parent Signature (Type in your name here to signify your agreement with and understanding of the above statements) *

Date

YYYY

The following information is for grant purposes. Please fill out these additional forms so that we can continue our programing.

Please indicate if you have access any of these services:

Boys & Girls Club

Big Brothers Big Sisters

YMCA/YWCA

NYS Dept. of Social Services

SCAP

Bethesda House

HEAP

Social Security (SSI/D)

BNI

Family of One ,Income size

Less than $18,900

Less than $31,500

Less then $50,350

More than $48,400

Clear selection

Family of Two, Income size

Less than $21,600

Less than $36,000

less than $57,550

More than $55,300

Clear selection

Family of Three, Income size

Less than $24,300

Less than $40,500

Less than $64,750

More than $62,200

Clear selection

Family of Four, Income size

Less than $26,950

Less than $44,950

Less than $71,900

More than $69,100

Clear selection

Family of Five, Income size

Less than $30,170

Less than $48,550

Less than $77,700

More than $74,650

Clear selection

Family of Six Income size

Less than $34,590

Less than $52,150

Less than $83,450

More than $80,200

Clear selection

Family of Seven, Income size

Less than $39,010

Less than $55,750

Less than $89,200

More than $85,700

Clear selection

Family of Eight or more, Income size

Less than $43,430

Less than $59,350

Less than $94,950

More than $91,250

Clear selection

I am registering my child for *

Week 1 July 8th -12 Pottery

Week 2 July 15th- 19th Diamond Art

Week 3 July 22nd -26th Painting and Drawing

Week 4 July 29th -August 2 Paper Mache

Week 5 August 5th- 9th Drumming Steel Pan and African drums

Week 6 August 12th -16th Mixed Media Art

Required

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