2008 HOPKINTON
SUMMER DAY CAMP
Camp is based out of the Harold Martin School Gymnasium
Open to youth Ages 6 - 12 years old
(One form per Camper)
2008 DATES & SESSIONS
Session I June 30-July 3 (4 days) -
Liquid Planet Water Park
Session II July 7-July 11 - Boston Aquarium
Session III July 14-July 18 - Whale Watch, Boston
Session I July 21-July 25 - Canobie Lake Park
Session V July 28-Aug 1 - Boston Museum of Science
Session VI Aug 4-Aug 8 - Water Country USA
Session VII Aug 11-Aug 15 - Fun Spot
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ABOUT THE PROGRAM The Hopkinton Summer Day Camp runs Monday thru Friday from 8:30am to 4:00pm. Early Drop-Off/Late Pick-Up Services begin at 7:30 AM and end at 5:00 PM sharp.
The Hopkinton Summer Day Camp offers arts & crafts, sports & games, field trips, swimming activities, canoeing, kayaking, and environmental programming for youth ages 6-12. Field trips are scheduled for every Wednesday and have included activities such as Whale Watch, trips to Clarks Trading Post, Boston Museum of Science, Whales Tail Water Park, and more. This year’s trips will be announced at a later date. We will also
take field trips on Fridays to various State Parks. Campers may be broken up into age groups depending on the activities of the day. Special theme days will be incorporated throughout the summer such as “Superhero day,” “Wild Wild
West,” “Extreme Sports Day,” and more. Campers are encouraged to come in costume on these days to earn extra points for their team competitions. |
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Please Mail Registration form and check to:
Hopkinton Recreation Department
330 Main Street
Hopkinton, NH 03229
HOPKINTON RECREATION DEPARTMENT
2008 SUMMER DAY CAMP REGISTRATION FORM
Weeks your child will be attending:
( ) Session 1 (6/30-7/3) ( ) Session 2 (7/7-7/11) ( ) Session 3 (7/14-7/18) ( ) Session 4 (7/21-7/25)
( ) Session 5 (7/28-8/1) ( ) Session 6 (8/4-8/8) ( ) Session 7 (8/11-8/15)
One child per form, please. Tuition is $85 per child per week ($75 for Session 1). Tuition includes all camp activities and covers admissions & transportation costs for field trips. Payment is due the Wednesday before your child is to attend. A one-time $10.00 non-refundable registration fee must be included with this form. Early Drop-Off/Late Pick-Up Services begin at 7:30 AM and end at 5:00 PM sharp. This will take place at Harold Martin School and will cost an additional $20/session.
Camper's Name______________________________Age_______ Date of Birth_______________
Address______________________________________________ Phone________________
School_____________________ Grade(fall)_____ M/F_____ T-Shirt Size________
PARENT / GUARDIAN:
Name(s) __________________________________________________________________________
Home Address _________________________________________ Phone _______________
ALTERNATE PICK-UP LIST:
Name______________________________________ Relationship_______________________
Name______________________________________ Relationship_______________________
ALTERNATE EMERGENCY CONTACT:
Name______________________________________ Relationship________________________
Address___________________________________________________ Phone______________
PERMISSION / AGREE TO HOLD HARMLESS:
I hereby give permission for my child to participate in the Summer Day Camp with the Hopkinton Recreation Department. I am aware of and assume all risks and hazards incidental to such participation, including transportation to and from camp and I do hereby waive, release and agree to hold harmless the town of Hopkinton, its Recreation Dept., sponsors, volunteers and staff, for any claim arising out of injury to my son/daughter or property damage that might occur.
PARENT SIGNATURE_____________________________________DATE ___________________
CAMPER HEALTH RECORD
The following information is to be completed by the parent. It will be held confidential and will be only used to benefit your child. PLEASE PRINT CLEARLY, SIGN and DATE.
Are there any significant findings that could influence the child’s adaptations to a child care/camp setting (.i.e., physical handicap, sensory problems or loss, developmental irregularities?)
Are there any chronic illnesses that may require regular medication, and other observations or precautions (i.e., recurrent ear infections, seizure disorder, allergies to outdoor influences, food, drugs or other allergies? (List any diet modifications or special medications.)
Has there been any potential exposure to any contagious diseases during the last 3 weeks? ______________
Any hospitalizations, operations, special test or reoccurring illnesses of which the child care/camp staff should be aware?
IMMUNIZATION & INFECTIOUS DISEASE HISTORY:
IMMUNIZATIONS UP TO DATE? (Y/N) Please provide dates for the following
POLIO, ORAL ____________ SCARLET FEVER ____________
POLIO, SALK ____________ CHICKEN POX ____________
DIPHTHERIA ____________ RUBELLA ____________
TETANUS ____________ MUMPS ____________
WHOOPING COUGH ____________ MEASLES ____________
OTHER ____________ OTHER ____________
PHYSICIAN NAME_______________________________________ PHONE_______________
ADDRESS ____________________________________________________________________
MEDICAL INSURANCE COVERAGE? (YES /NO)
COMPANY NAME_______________________________ ID#___________________________
In case of emergency, I hereby give permission to the medical personnel selected by the camp, in my absence, to act as my agent in securing proper medical treatment for my child as named above, including hospitalization, routine tests, X-rays and other medical treatment. Every possible effort will be made to contact parents in the event of an emergency.
PARENT SIGNATURE____________________________________ DATE_________________
RELEASE & PERMISSION FORM
2008 HOPKINTON SUMMER DAY CAMP
Child's Emergency
Name____________________________________ Phone # __________________
Session # 1 (4 days) |
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X |
$75 |
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Session # II – VII (5 days) |
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X |
$85 |
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# Of weeks, late/early drop off |
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X |
$20 |
= |
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Registration Fee, one time (non-refundable) |
1 |
X |
$10 |
= |
$10 |
Non-Resident Fee per session |
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X |
$20 |
= |
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Total Due |
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= |
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Total Enclosed |
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= |
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Photo Release
I hereby grant the Town of Hopkinton permission to use my child’s photograph, video picture, and/or other digital reproduction of him/her or other reproduction of his/her physical likeness for publication processes, whether electronic, print, digital or electronic publishing via the Internet or other Recreation Department materials.
Please Check:
______Accept _____Decline
Parent’s signature ____________________________________
My signature verifies the following:
I hereby give my permission for my child to participate in the above listed Hopkinton Recreation Department Summer Day Camp and trip(s) associated with camp. I assume all risks and hazards incidental to such participation. I do hereby waive, release and agree to hold harmless the said town, it’s volunteers, staff and all sponsors for any claim arising out of injury to my child or property damage that might occur during their participation. I am aware of the hazards of the trip and the risk of injury associated with it.
In case of emergency, I hereby give my permission to the day camp staff and medical personnel selected by the staff, in my absence, to act as my agent, to apply simple first aid or when necessary to administer more serious medical attention. Also, I give permission for my child to be transported to an emergency medical facility and to receive emergency medical attention. I also authorize the medical personnel to administer such treatment as is medically necessary. I authorize the hospital to undertake examination and emergency treatment if warranted on behalf of my child. Every effort will be made to contact parents in event of an emergency.
Parent’s Signature _______________________________________ Date ____________
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