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Camp Clio 2015 Application
Last name: First name: Gender:
Birthdate: Grade in Sept.
2015: Returning camper? yes / no
Age at camp: Family
address:
city state zip
One cabinmate request (must be mutual)
Parent 1 * info Parent 2 info Emergency contact 1 Emergency contact 2
Last name:
First name:
Home phone
Work phone
Cell phone
Relationship
* primary contact for camper communications
Please choose All-Day or Residential camper and check the box for each session being requested
Sessions: All-Day Camp Sessions: Residential Camp
1 June 28 – July 4, 2015 1 June 28 – July 4, 2015
2 July 5 – July 11, 2015 2 July 5 – July 11, 2015
3 July 12 – July 17, 2015 3 July 12 – July 18, 2015
* Saturday stayovers: Saturday July 4, 2015
Saturday July 11, 2015
Saturday night stay is ONLY for campers living outside CT Please complete to calculate your total charges
number of Day sessions @ $ 400/week $
number of Residential sessions @ $550/week $
Leaders in Training Program (sessions 1,2,3) @ $ 1,350 $
Counselors in Training Program (sessions 2-5) @ $1,600 $
number of Saturday stayovers @ $50.00 $
Total $
($250 deposit for each week requested) Deposit $ ( )
Please choose Method of Payment
Balance $
Check # __________
to be paid at least 3 weeks prior to camper's arrival date
Money order
Credit card (attach authorization form)
Parent Questionaire/Release/Abuse & Neglect policy must be signed and returned along with this application
Signature__________________________________________________________Date__________________________________
Camp Claire 2015 Parent Questionnaire/Release/Abuse & Neglect Policy Camper’s Name _____________________________________ Nickname __________________________ Please complete the following questions to help us give your child the best possible camp experience. This information will only be shared with the staff that need to know and with the best interests of your child in mind. Has your child been to camp before? __________________________________________________________ How did you hear of Camp Claire? __________________________________________________________ Does your child have any special dietary needs? _________________________________________________ _________________________________________________________________________________________ What are you hoping for your child to gain by attending camp? ______________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________
Has your child been diagnosed with any learning disabilities, emotional or behavior problems, or are there any concerns camp should be aware of? ____________________________________________________________
_________________________________________________________________________________________ _________________________________________________________________________________________ Releases: May your child participate in walks near camp property? Yes No
May your child participate in Camp Claire based canoe trips on the Connecticut River? Yes No May your child participate in Camp Claire Low Challenge Ropes Course activities? Yes No May your child be photographed for Camp Claire/Camp Clio advertisements or camp newspaper? Yes No I understand that if my child engages in drug use, alcohol use, abusive language, inappropriate sexual behavior, aggression toward another person, or in possession of firearms or fireworks,
he/she will be asked to leave Camp Claire immediately and at their own expense. Yes No
Parent signature _____________________________ Date ________
Abuse and Neglect Policy: You have entrusted your child/children’s care to the staff of Camp. Claire. We are committed to providing the best
possible and most appropriate learning/fun experiences for your child/children. Occasionally there are factors in a child’s appearance and behavior that lead to suspicions of child abuse or neglect. Connecticut law requires that all childcare professionals, including all staff of a childcare program/camp, report suspected abuse or neglect to the Department of Child and Families’ Child Abuse and Neglect Hotline (1-‐800-‐842-‐2288) or the local police in order that children may be protected from harm and that the family be helped.
Staff are mandated reporters and have been instructed to report suspected incidents of child abuse. Failure to do so may result in disciplinary action up to and including termination of employment.
Should you have difficulty in providing for your child’s emotional and physical needs, you are encouraged to ask for help. Our staff can help you in finding community resources, which can offer assistance to your family.
Should you at any point during your child’s enrollment, have any questions or concerns about your child’s care or safety, we encourage you to speak immediately to the Director or contact other personnel.
I have read and understand Camp Claire’s Abuse and Neglect Policy.
Parent signature _____________________________ Date ________
Camp Clio Questionnaire What size t-‐shirt does your child wear? _____________________________________ How did you hear about Camp Clio? _________________________________________ From where was your child adopted? _______________________________________ At what age was he/she adopted? ___________________________________________ Does your child ask for help when needed? _________________________________ If not, what does your child look like when he/she needs help? ___________________________________________________________________________________ ___________________________________________________________________________________ Does your child have any fears? ______________________________________________ ___________________________________________________________________________________ Does your child have any sensory issues or environmental triggers? ___________________________________________________________________________________ ___________________________________________________________________________________ What support does your child need to have a successful experience at camp? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
Camp Clio Scholarship Application ___________ I would like to apply for a scholarship to Camp Clio. _____________ Does your child receive a free school lunch? Briefly state your reason for applying for a scholarship and send it with your application.
Camp Claire Credit Card Authorization Form Camp Claire offers a credit card payment option for those campers wishing to use a credit card for payment rather than a check. The following provisions apply for those wishing to use a credit card:
1. Payment in full is required at the time of application. Not a deposit. 2. A 4% fee must be added to the amount due to cover the costs of credit card processing.
Please complete the following if credit card payment is requested: Cost of session(s) your camper is registering for (from the application form) $________________ 4% processing fee (multiply the amount above by 0.04) + $ ________________ Total amount to be charged to your credit card = $ ________________
Credit card to be charged (please circle one):
American Express Discover MasterCard Visa
Card number _______________________________ Expiration date _______________________________ Security code (on back of card) _______________________________
Name as it appears on card _______________________________
Billing address _______________________________ _______________________________ _______________________________
Signature of authorized cardholder _______________________________ Date ____________________