CAMP FIRE NORTH SHORE - SHOEMAKER - BEFORE SCHOOL PROGRAM - REGISTRATION 2021-2022
REGISTRATIONS RECEIVED FROM SEPTEMBER 9TH ON WILL NOT BE ABLE TO START PROGRAM UNTIL WEDNESDAY, SEPTEMBER 15TH.

We will be using this form to collect registration for the BEFORE School Program at Shoemaker. Registration is first come, first serve.  

Shoemaker Before School Program starts at 7 am until the start of school Monday through Friday.

Shoemaker Before School Program is open only to Shoemaker students.

Cost:  $11 per day

There is a minimum of two days required to attend.

The Before School Program will begin on Monday, September 13, 2021.
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Please complete one survey for EACH child you need to enroll.  
What program do you want to register for? *
Required
What days of the week will your child attend (2 days minimum required)?                                              REGISTRATIONS RECEIVED FROM SEPTEMBER 9TH ON WILL NOT BE ABLE TO START PROGRAM UNTIL WEDNESDAY, SEPTEMBER 15TH. *
Required
Will you be using a Child Care Circuit voucher? *
Child First Name *
Child Last Name *
Gender *
Birth Date *
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DD
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Grade ( Fall 2021) *
Is Child Hispanic/Latino *
Child Race *
Required
What language does your child understand/speak best? *
What languages are spoken in the child's home? *
Required
Height *
Weight *
Eye Color *
Hair Color *
Identifying Marks *
Are there any custody agreements, court orders or restraining orders pertaining to the child? *
Does your child have allergies? *
If yes, please list allergies:
Does your child need an EPI PEN or other medication for his/her allergy while at the before school program? *
If yes, please list medications your child needs to take while at before school program.
Does your child have any chronic health conditions or physical/health/developmental limitations or disabilities? *
If yes, please list any chronic health conditions or physical/health/developmental limitations or disabilities?
Physician Name *
Physician Address *
Physician Phone *
Health Insurance Company *
Physical with Immunization Records  - These documents are required to attend program
Please email required documents to mcole@campfirenorthshore.org
COVID-19 Daily Health Screening Parent/Guardian Agreement                 My child will not attend the Before School program if any of the following are true: 1. My child has or had any of the following symptoms within the last 24 hours:• Fever of 100° or above• Chills or shaking chills• Cough (not due to other known cause, such as chronic cough)• Difficulty breathing or shortness of breath• New loss of taste or smell• Sore throat• Headache when in combination with other symptoms• Muscle/body aches• Nausea, vomiting or diarrhea• Fatigue when in combination with other symptoms• Nasal congestion or runny nose when in combination with other symptoms 2. My child has a positive or pending COVID-19 test3. My child has been exposed to anyone diagnosed with COVID-19 within the past 14 days*4. My child has been exposed to anyone in the household exhibiting COVID-19 symptoms*5. My child has been instructed to quarantine or isolate 6. My child has been given fever reducing medication*Item numbers 3 & 4 only apply to individuals who have NOT been vaccinated .I agree to monitor my child daily for the above listed items (#1-6) throughout the program session and to keep my child home until cleared by the local health department. I agree to notify the Camp Director (781-234-5330) should my child experience any of the above listed items.
Parent/Guardian Consent for COVID-19 Daily Health Screening *
TERMS OF AGREEMENT
I enter into this contract with the full knowledge of my obligation and my agreement to meet the following policies of Camp Fire North Shore:
To complete a child registration and pay a non-refundable Family Fee of $20.00/child or $30.00/family. The registration must include all pertinent information related to the safety of my child and I agree to update all of the information as necessary throughout the year.  This includes changes in phone numbers, address, medical history, emergency contacts, etc.
To pay tuition on Mondays, one week prior to my child attending the program whether or not my child is in attendance. This is a full week in advance. This includes when my child is sick and away on vacation when the program is open.
To pay a late fee of $10.00 for tuition payments received three or more days after the Monday due date. Any payments due in a given week will be assessed this late fee if payment is not received by close of business Wednesday.
To pay a late fee of $10.00 per fifteen minutes if I do not pick up my child by the closing of the program.  Continuous tardiness could result in termination of my child from the program.
To provide a two-week cancellation notice to the Main Office should I choose to terminate my child's registration. If notice of cancellation is not received 14 days prior to service, I will be financially responsible for the remaining tuition. Refunds on tuition and exemptions to the 14 day rule are made only for documented medical reasons causing a child to withdraw. A written notice from your health care provider must be provided.
I understand that I am not obligated to pay for scheduled holidays and school vacation days, per the published school district calendars. I am responsible to pay snow and/or inclement weather days throughout the school year.  
I understand there will be no deduction in tuition if my child is absent from school or the Camp Fire program due to illness, extracurricular activities, inclement weather, or any other condition beyond the control of the Camp Fire program.
I further understand that if I fall behind in tuition payments, the Camp Fire Extended Day Programs will terminate my child’s participation in the program, effective immediately. This action will not alter my obligation to pay the balance due.
Massachusetts health regulations require all participants to have a current physical and immunization record on file before the child may attend program. I understand my child cannot be admitted to program without this documentation.
Participants will wear a face mask or covering while at program. I understand that my child cannot be admitted to program without a face mask or covering.
Massachusetts reopening regulations require programs to establish an emergency communication system. Camp Fire North Shore staff and Directors will use the REMIND APP to communicate emergency and general information to parents/guardians. I agree to download and monitor the REMIND APP.
I agree to call the Camp Fire Main Office or the Camp Fire school site cell phone if my child will be out sick or is going to be absent.
I understand that my child may be terminated from the program due to behavior or other issues, per the policy listed in the Parent Handbook. This action will not alter my obligation to pay the balance due.
I authorize Camp Fire North Shore to photograph/video my child while involved in program activities. I understand these pictures will only be used for Camp Fire promotion, marketing and for Camp Fire projects.

FIRST AID AND EMERGENCY MEDICAL CARE CONSENT:
I authorize staff in the child care program who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and to secure necessary medical treatment for my child.

TRANSPORTATION PLAN FOR PROGRAM:
I agree to keep emergency contact/authorized pick up information updated in the Regpack registration system.  I, or an authorized contact, will pick up my child and sign the child out at the end of the program day.
 
TRANSPORTATION PLAN FOR WALKING FIELD TRIPS:
I hereby give permission for my child to participate in walking field trips (weather permitting) with members of the Camp Fire staff (to locations such as a playground, field, park, etc.). Children will bring their belongings with them so that they can be picked up at the off-site location.
Parent/Guardian Consent for Terms of Agreement: *
Does your child receive ELL services at school? *
Does your child received special education services at school? *
To best meet the personal and educational needs of my child, I give permission to Camp Fire North Shore’s staff to speak to teachers, administrators, social workers and additional support staff at my child’s school. I hereby authorize the above mentioned individuals to release and share information on my child, including, but not limited to attendance, report cards, IEPs, 504 Plans, progress reports, and behavior charts. I understand that all information shared will be kept confidential and will only be used to work towards my child’s personal and educational goals and to enhance my child’s overall before and after school experience. No school records may be released to any other person or agency without my full permission. *
Emergency Contact Information - include Name and Phone Number *
Name of Parent/Guardian completing from *
Email of Parent/Guardian completing form *
Phone number of Parent/Guardian completing form *
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