2009 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)
2009 DATES & SESSIONS
Session I - June 29 - July 3
Session II - July 6 - July 10
Session III - July 13 - July 17
Session IV - July 20 - July 24
Session V - July 27 - July 31
Session VI - Aug 3 - Aug 7
Session VII - Aug 10 - Aug 14
ABOUT THE PROGRAM
The Hopkinton Summer Day Camp offers arts & crafts,
sports & games, field trips, swimming activities, kayaking,
cabin trips and more, for youth ages 6-12.
Field trips are scheduled for every Wednesday
Session I field trip – Whales Tale Water Park
Session II field trip – Boston Museum of Science
Session III field trip – Water Country
Session IV field trip – Fisher Cats Baseball Game (Thurs)
Session V field trip – Canobie Lake Park
Session VI field trip – Strawberry Banke
Session VII field trip - Funspot
On Fridays we will take field trips to various State Parks.
Campers may be broken up into age groups depending on the activities of the day.
Theme days will be incorporated throughout camp!
CAMP HOURS & LOCATION~
Camp operates Monday through Friday, rain or shine. Drop off and pick up location is at Harold Martin School. Activities take place in and around the school.
Normal Camp Times:
Arrival Time: 8:30 am
Pick-up Time: 4:00 pm
Early Drop-Off/Late Pick-Up Service ($25 Extra):
Arrival Time: 7:30 am
Pick-Up by: 5:00 PM
HOPKINTON RECREATION DEPARTMENT
2009 SUMMER DAY CAMP REGISTRATION FORM
Weeks your child will be attending:
( ) Session 1 (6/29-7/3) ( ) Session 2 (7/6-7/10) ( ) Session 3 (7/13-7/17) ( ) Session 4 (7/20-7/24)
( ) Session 5 (7/27-7/31) ( ) Session 6 (8/3-8/7) ( ) Session 7 (8/10-8/14)
One child per form, please. Tuition is $85 per child per week. Tuition includes all camp activities and covers admissions & transportation costs for field trips. Payment is due the Wednesday before your child is to attend. 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 $25/session.
Camper's Name__________________________________________ Age_______ Date of Birth_______________
Address______________________________________________ Phone________________
School_____________________ Grade(fall)_____ M/F_____ T-Shirt Size________
PARENT / GUARDIAN:
Name(s) ________________________________________________
Email________________________________________
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
2009 HOPKINTON SUMMER DAY CAMP
Child's Name____________________________ Emergency Phone # __________________
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$85 |
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$25 |
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Non-Resident Fee per session |
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$25 |
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Total Due |
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Total Enclosed (you must pay for at least one session) |
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Please circle sessions attending I II III IV V VI VII |
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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 ____________
Please Mail Registration form and check to:
Hopkinton Recreation Department
330 Main Street
Hopkinton, NH 03229
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