SCCNS Inchworm 3s Camp Registration Form

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THIS APPLICATION IS FOR THE 2024 *THREES* INCHWORM PROGRAM, which is a six week half-day program in session Mondays through Thursdays. Campers should be entering a 3s program in September 2024. If your child will be entering a 4s program or K in September, please go back to http://sccnurseryschool.com/programs/inchworm-camp/ to select the appropriate application form.

Email *

Tuition for Session 1 only: $695
Tuition for Session 2 only: $755

Tuition for both Sessions: $1,450

I wish to enroll my child in the following session(s):

Session 1

Session 2

Required

CAMPER INFORMATION

Camper Name: *

Camper Nickname (if preferred over full name):

Camper Date of Birth: *

YYYY

Camper Address (Street number / name): *

Camper Address (Town or City, State): *

Camper Identifies as: *

Female

Male

Prefer not to say

Other:

PARENT/CAREGIVER INFORMATION

Parent/Caregiver 1 Name:
*

Parent/Caregiver 1 Email:
*

Parent/Caregiver 1 Phone (Please enter in XXX-XXX-XXXX format):
*

Parent/Caregiver 2 Name:

Parent/Caregiver 2 Email:

Parent/Caregiver 2 Phone (Please enter in XXX-XXX-XXXX format):

Emergency Contacts (please enter names and phone numbers, other than Parents/Caregivers listed above):
*

Pediatrician Name:
*

Pediatrician Phone (Please enter in XXX-XXX-XXXX format):
*

Does your child receive any services (Speech, OT, PT, etc)?
*

Does your child have any allergies or take medication on a regular basis?
*

Is there any additional information we should know about your child? For example, social or behavioral concerns, first time in a classroom setting, other languages spoken at home, etc.

FORMS & WAIVERS

Please confirm your understanding of the electronic signature for the following forms and waivers: By selecting "I agree" to the following questions using any device, means, or action, you consent to the terms and conditions of each agreement. You further agree that your signature on this document is as valid as if you signed the document in writing. You also have the option of signing a paper document for each of the following, in lieu of this electronic signature, which can be provided to you by contacting the school at sccnschool@gmail.com or 914-723-2440.
*

I understand and choose to use an electronic signature

I would prefer to sign a paper copy and will be contacting the school to do so

SCCNS follows NYS regulations regarding immunizations, which can be found here: https://www.health.ny.gov/publications/2370.pdf; as such, we require a current medical form, including immunizations, be submitted prior to the start camp, and updated throughout the summer if applicable. Please confirm how you will submit your child's form:
*

I will be emailing a copy of my pediatrician's form to sccnsForms@gmail.com

I need to submit a paper copy of my pediatrician's form and will do so during school hours, on or before June 1, 2024

I have submitted an updated form for my child in the last 6 months

Please review the SCCNS Medical Waiver of Liability and Permission to Seek Medical Treatment, located here: https://drive.google.com/file/d/1clOFW1cLKN97fnE5fOeJczRqGs3b1TSi/view?usp=sharing
*

I agree

I do not agree

Benadryl Administration Consent: Allergies can present themselves unexpectedly and/or for the first-time with pre-school age children. By agreeing below, I consent to SCCNS Inchworm staff administering Diphenhydramine Hydrochloride (Benadryl) if my child appears to present symptoms of an allergic reaction to food, an insect bite or other allergen. Note: If the child has a diagnosed allergy, which I have disclosed to SCCNS Inchworm Staff, staff will follow the protocol I provide.
*

I agree

I do not agree

Permission to Change Clothing & Diapers: By agreeing below, I hereby give permission to the SCCNS Inchworm Staff to change my child’s diaper or clothing, as they reasonably deem appropriate.
*

I agree

I do not agree

AFFIRMATIONS

Please read and confirm the below. If you have any questions or concerns please contact the school at 914-723-2440 or sccnschool@gmail.com to discuss.
*

I understand and agree

I understand that occasionally a student requires more care and attention than SCCNS is reasonably able to provide, and SCCNS reserves the right to determine whether a child’s admittance or continued attendance in the program is appropriate.

In so registering my child, I recognize my responsibility to cooperate with SCCNS by observing all health regulations, protocols, and financial obligations.

I understand that payment is required in full within 24 hours of receiving an invoice, or my child’s spot will be forfeited, and I am aware that SCCNS has a no refunds policy for the Inchworm Program (details and further explanation can be found in the 'Inchworm FAQs' document sent out by the SCCNS Director)

I understand and agree

In so registering my child, I recognize my responsibility to cooperate with SCCNS by observing all health regulations, protocols, and financial obligations.

A copy of your responses will be emailed to the address you provided.

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