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summer camp form

Child 1 Name :

Gender :

DOB :

AGE : 01/05/1980

T-Shirt :

Address :

City :

Zip :

Mother’s Name :

Cell :

Other :

Father’s Name :

Cell :

Other :

Mother’s Email :

Father’s Email :

Child Primarily Lives with :

Mom & Dad

Mom

Dad

Other (please explain) :

How did you hear about STEM Academy :

Referred by :

Select Session :

5 FULL DAYS
8:30am – 4:30pm
$350/wk or $325/wk*

3 FULL DAYS
8:30am – 4:30pm
$250/week

5 HALF DAYS
8:30am – 12:30pm
$250/week

BEFORE CARE
7:00am – 8:30am
$10 per hour

AFTER CARE
4:30pm-7:00pm
$10 per hour

*$325 per week when selecting a minimum of 7 weeks and 5 full days.
*Before Care & After Care are included with 5 full day option.

Select Dates

Weeks	June
Week 1	26	27	28	29	30
Week 2	3	4	5	6	7
Week 3	10	11	12	13	14
Week 4	17	18	19	20	21
Week 5	24	25	26	27	28

Weeks	July
Week 1	26	27	28	29	30
Week 2	3	4	5	6	7
Week 3	10	11	12	13	14
Week 4	17	18	19	20	21
Week 5	24	25	26	27	28

Weeks	August
Week 6	31	1	2	3	4
Week 7	7	8	9	10	11
Week 8	14	15	16	17	18
Week 9	21	22	23	24	25
Sign up for more than 7 weeks & enjoy a discount!

Drop off time :

BEFORE CARE :

Pick up time :

AFTER CARE :

BEFORE & AFTER CARE TUITION

	TUITION		WEEKS		SUBTOTAL
CAMPER 1		x		=

PAYMENT	TUITION		WEEKS		SUBTOTAL		DISCOUNTS		TOTAL
CAMPER 1		x		=		-		=

Lunch Program at STEM $6 per meal

MEDICAL INFORMATION (please share any allergy/medical/therapies/behavioral concerns)

EMERGENCY MEDICAL RELEASE

This is to certify that I voluntarily furnish medical information on the above-designated student to STEM ACADEMY FOR YOUNG KIDS. I hereby request that in the event that emergency medical care for my child. I further give my consent for an emergency medical facility or physician to administer necessary medical treatment to my child if I am unable to be reached or the situation requires immediate attention. I understand that I am responsible for paying all medical bills.

INITIAL :

PRIMARY CARE PHYSICIAN :

PHONE :

MEDICAL INFORMATION (please share any allergy/medical/therapies/behavioral concerns)

EMERGENCY MEDICAL RELEASE

INITIAL :

PRIMARY CARE PHYSICIAN :

PHONE :

EMERGENCY CONTACT INNFORMATION - Parents notified first, next in priority.

Contact #1 Name :

Relationship :

Phone :

CHILD RELEASE AUTHORIZATION

List names of ANY individuals who are authorized to pick up your child, besides yourself. If anyone else will be picking up your child, please notify the ofﬁce and use an AUTHORIZATION PICK UP FORM. STEM ACADEMY cannot release your child to anyone not authorized to pick up without written consent. All individuals will need to provide a photo ID when picking up.

Name #1 :

Relationship :

Address :

Phone :

ACKNOWLEDGMENT OF WAIVER AND RELEASE

By signing this form I confirm to pay my tuition fees AND I confirm I realize all risks related to the transportation, activity and environment. I confirm waiving, releasing and discharging STEM Academy For Young Kids and its associates from any and all claims of liability or expenses of any kind and/or nature whatsoever arising out of or relating to my child/ren’s participation in the Enrichment and Care Programs.

PRINT NAME :

SIGNATURE :

DATE :

Terms of Enrollment

No make ups, credits & refunds.
All deposits/registration fees are non-refundable.
You will be obligated for dates chosen on this form.
We reserve the right to dismiss a camper whose conduct or influence is not the best interest of our camp group for the safety of our campers.
All balances will be charged on June 1, 2017.
Registration fee is $100 per child & non-refundable.
Field Trips are an additional cost.
Bring your own lunch or buy $6 per meal.

Initial Here

Office Use Only Notes

Initial Here

Policy on the release of children (N.J.A.C. 10:122-6.5):
New Jersey Regulation

Each child may be released only to the child’s parent(s) or person(s) authorized by the parent(s) to take the child from the center and to assume responsibility for the child in an emergency if the parent(s) cannot be reached.

If a non-custodial parent has been denied access, or granted limited access to a child by a court order, the center shall secure documentation to that effect, maintain a copy on ﬁle, and comply with the terms of the court order.

If the parent(s) or person(s) authorized by the parent(s) fails to pick up a child at the time of the center’s daily closing, the center shall ensure that:

The child is supervised at all times.
Staff members attempt to contact the parent(s) or person(s) authorized by the parent(s); and
An hour or more after closing time, and provided that other arrangements for releasing the child to his/her parent(s) or person(s) authorized by the parent(s) have failed and the staff member(s) cannot continue to supervise the child at the center, the staff member shall call the 24- hour Child Abuse Hotline 1-877-NJ-ABUSE to seek assistance in caring for the child until the parent(s) or person(s) authorized by the child’s parent(s) is able to pick up the child.

If the parent(s) or person(s) authorized by the parent(s) appears to be physically and/or emotionally impaired to the extent that, in the judgment of the director and/or staff member, the child would be placed at risk of harm if released to such an individual, the center shall ensure that:

The child is supervised at all times.
Staff members attempt to contact the child’s other parent or an alternative person(s) authorized by the parent(s); and /li>
An hour or more after closing time, and provided that other arrangements for releasing the child to his/her parent(s) or person(s) authorized by the parent(s) have failed and the staff member(s) cannot continue to supervise the child at the center, the staff member shall call the 24- hour Child Abuse Hotline 1-877-NJ-ABUSE to seek assistance in caring for the child until the parent(s) or person(s) authorized by the child’s parent(s) is able to pick up the child.
If the center is unable to make alternative arrangements, a staff member shall call the 24hour Child Abuse Hotline 1-877-NJ-ABUSE to seek assistance in caring for the child.

Photo Consent

Child 1 Name :

grade :

AGE : 3 years 2 months

Gender :

Yes, I do give my consent to STEM Academy to use photo or video images taken of my child in school brochures, advertisements for the school, on the website, in social media and in other school publications as they see fit. I agree to hold harmless STEM for Young Kids from any liability which may result from the use of said picture(s). This form will apply throughout my child’s tenure at STEM Academy for Young Kids and will not need to be updated unless I so desire.

Yes, with the following limitations listed below – if none apply, please use N/A.

No, I do not give my consent to STEM Academy to use pictures taken of my child in school brochures, advertisements for the school, on the website, in social media and other school publications as they see fit.

Name of Parent or Guardian (print) :

Signature of Parent or Guardian :

Date :

ALLERGY ALERT PAGE

This page is designed for parents of children with allergies. Our first priority at STEM Academy is your child’s safety. Please help us by completing the information below and speaking directly with the center director concerning your child’s allergy.

child first name :

child last name :

List known ALLERGY/ALLERGIES below: :

Does your child have an EPI pen?

Yes

Does your child use Benadryl?

Yes

Have you supplied the center with Benadryl and/or Epi pen in the original box with your child’s information label on it?

Yes

Did your doctor fill out an allergy action plan?

Yes

PARENT’S OF CHILDREN WITH ALLERGIES MUST DISCUSS ANY/ALL DIETARY ISSUES WITH THE DIRECTOR UPON ENROLLMENT. WE STRONGLY ENCOURAGE PARENTS OF CHILDREN WITH ALLERGIES TO SUPPLY ALL THEIR CHILD’S FOOD AND BOWLS.

Parent/Guardian Signature:

Date :

Director Signature :

Date :

DEAR PARENT:

In keeping with New Jersey’s child care center licensing requirements, we are obliged to provide you, as the parent of a child enrolled at our center, with this informational statement.

The statement highlights, among other things: your right to visit and observe our center at any time without having to secure prior permission; the center’ s obligation to be licensed and to comply with licensing standards; and the obligation of all citizens to report suspected child abuse/neglect/exploitation to the State Central Registry Hotline (877) NJ ABUSE (877) 652-2873.

Please read this statement carefully and if you have any questions, feel free to contact me at:

732-243-9793 or info@gostemacademy.com

Sincerely,
Director
STEM Academy for Young Kids

Please complete and return this portion to the center. (Please Print)

Name of Child :

Name of Parent(s) :

I have received and read a copy of the Info to Parents statement prepared by the Ofﬁce of Licensing, Child Care & Youth Residential Licensing, in the Department of Children and Families.

Signature :

Date :

DEAR PARENT:

STEM ACADEMY FOR YOUNG KIDS SUMMER CAMPS WAIVER AND RELEASE OF LIABILITY AND NAME AND LIKENESS A PARENT, LEGAL GUARDIAN, OR EMPOWERED REPRESENTATIVE OF EACH MINOR CHILD(REN) REGISTERING TO ATTEND STEM ACADEMY FOR YOUNG KIDS SUMMER CAMPS (THE “CAMP”) MUST AGREE TO THE TERMS OF THIS WAIVER AND RELEASE OF LIABILITY AND NAME AND LIKENESS PRIOR TO THE CHILD(REN) PARTICIPATING IN THE CAMP.

I, on behalf of myself and my Child(ren), hereby acknowledge and agree that:

Name and Likeness Release:

In consideration for my child(ren) being permitted to participate in the Camp, I hereby grant permission to STEM Academy For Young Kids Camps, Omni Services LLC and each of its affiliated or subsidiary companies, their successors, agents, and assigns (“STEM Academy For Young Kids”) to utilize my child(ren)’s name, voice, and likeness (including, but not limited to, photographs and any video/audio recording of my child(ren)’s appearance at the Camp) in any and all manner and media, now known or hereafter developed, throughout the universe in perpetuity without limitation and without additional compensation or consideration, notification, or permission, unless prohibited by applicable law. I hereby waive any right that I or my child(ren) may have to inspect or approve any finished product (including, but not limited to, any camp blog, brochures, videos, slide shows, web sites, and/or other materials) or any advertising copy that may be used in connection therewith or the use to which it is applied.

I hereby warrant that I have the right to make this release on behalf of my child(ren) and that my granting this waiver and release and the rights conveyed thereby will not infringe upon the rights of any third party. I hereby assign all rights, title, and interest my child(ren) or I may have in any and all media now known or hereafter developed in which any or all of my child(ren)’s appearance, name, voice, and/or likeness have been captured in connection with the Camp to STEM Academy For Young Kids, along with full rights of assignability.

I understand and agree that any photographs and/or video/audio recordings I make of my child(ren) at the Camp shall be used solely for my and his/her/their private, noncommercial use, and that absolutely no sale, transmission, distribution, or commercial use of any such photographs and/or video/audio recordings or descriptions are permitted.

Physical Condition:

On behalf of my child(ren), I accept and assume any and all risks associated with his/her/their attendance and participation in the Camp and all related activities. I understand that my child(ren) should not attend the Camp if he/she/they are not in a healthy condition. Furthermore, I do hereby 2 STEM Academy For Young Kids verify that my child(ren), to the best of my knowledge, is free from contagious disease, is fully immunized, and is able to participate in the Camp.

Therefore, I hereby confirm that my child(ren):

Has no medical, and/or physical condition or history which would prevent him/her/them from participating in the Camp and/or endanger himself/herself/themselves or others at the Camp;
Has not been instructed by any physician to refrain from participating in the Camp; and
Is physically fit and able to participate in the Camp.

Medical Treatment:

In connection with any injury my child(ren) may sustain or illness or other medical conditions my child(ren) may experience during his/her/their participation in or attendance at the Camp, I authorize any emergency first aid, medication, medical treatment, or surgery deemed necessary by the attending medical personnel if I am not able to act on my child(ren)’s behalf.

In the event that I cannot be contacted in the event of an emergency, I further hereby grant STEM Academy For Young Kids permission to administer immediate treatment and/or take my child(ren) to a hospital emergency room via ambulance/emergency vehicle.

I further authorize the attending medical personnel to execute on my child(ren)’s behalf any permission forms, consents, or other appropriate documents relating to medical attention. I agree to assume all liability for any expenses incurred in such an emergency (transportation, hospitalization, x-rays, etc.).

I also understand and agree that STEM Academy For Young Kids will notify me if my child(ren) becomes ill during camp hours, and I will arrange to have my child(ren) picked up immediately from Camp. Further, I waive and release STEM Academy For Young Kids and its owners, officer, directors, employees, agents and independent contractors from any and all liability for personal injuries, illness, loss, or damage to property.

Camp Policies and Rules:

I understand and agree that my child(ren) must abide by the Camp policies and rules and the instructions of the Camp organizers, employees, staff, counselors, and volunteers at all times, and that my child(ren)’s failure to do so will result in his/her/their immediate dismissal from the Camp. Some of these policies, rules, and instructions are written and some are at the sole discretion of the Camp organizers, employees, staff, counselors, and volunteers; however, it is understood that all policies, rules, and instructions seek at all times to ensure the overall safety of the Camp and each of its participants.

Furthermore, should my child(ren) fail to behave in an appropriate manner, intentionally harm another participant, exhibit signs of illness, or violate any Camp policy and rule, I shall promptly retrieve my child(ren) when contacted by STEM Academy For Young Kids to do so, or, if I am unable to do so, notify STEM Academy For Young Kids of the person retrieving my child(ren) on my behalf. 3 STEM Academy For Young Kids I acknowledge and agree that no part of the tuition paid will be refunded to me should my child(ren) be dismissed from the Camp. I also understand and agree that no reduction or prorate in the tuition will be made for late arrivals, early departures, vacations, illness, or injury.

Initial :

Date :

Assumption of Risk:

I understand that my child(ren), and each participant in the Camp, will be engaging in activities that may involve the risk of serious personal injury, illness, permanent disability, dismemberment, and death, and that also involve the risk of severe economic and property loss and damage. I understand that these risks may result from the actions, negligence, and failure to act of my child(ren) and others (including, but not limited to, other participants in Camp, and the organizers, employees, staff, counselors, and volunteers, if any, of the Camp) and the condition of any real or personal property, facilities, or equipment used during the Camp. I also understand that there may be risks involved in any and all activities which my child(ren) may participate which are not known to me, my child(ren), STEM Academy For Young Kids, or its organizers, directors, members, employees, staff, counselors, and volunteers, if any, and may not be foreseen or reasonably foreseeable by any of the foregoing entities or persons at this time or at the time of the Camp.

For my child(ren) at camp, these activities and associated risks may include time in the pool and transportation via motorized vehicle (shuttle, coach, and/or school bus) to and from camp and between different segments of the Camp during camp hours. Permission is granted to STEM Academy For Young Kids to transport my child(ren) via motorized vehicle to and from the Camp during camp hours and between different segments of the STEM Academy For Young Kids location/facility and any outside facilities used by STEM Academy For Young Kids during the Camp.

In consideration for my child(ren) being permitted to participate in the Camp, I, on behalf of my child(ren), assume all of the foregoing risks, including, but not limited to, the risk of any negligence by other Camp participants or by STEM Academy For Young Kids, and its respective owners, partners, directors, officers, employees, and agents, and the risk of injury caused by the condition of any real or personal property, facilities, or equipment used during the Camp, and accept personal responsibility for any injury (including, but not limited to, personal injury, disability, dismemberment, and death), illness, damage, loss, claim, liability, or expense (including reasonable attorneys’ and professionals’ fees), of any kind or nature, that my child(ren) or I may suffer arising out of or in any way connected with the Camp or my child(ren)’s participation in or attendance at the Camp.

Furthermore, I, on behalf of my child(ren) agree to indemnify and hold harmless STEM Academy For Young Kids and its owners, partners, directors, officers, employees, and agents from any claim that I might have arising out of my child(ren)’s participation in, transportation by, or involvement with the Camp.

I understand that my child(ren) are fully responsible for complying with all rules and regulations of the Camp and any motorized vehicle service and that STEM Academy For Young Kids reserves the right to cancel my child(ren)’s participation in the Camp or motorized vehicle service at any time.

I further understand that while STEM Academy For Young Kids will make every effort to minimize lost items at the Camp or on the motorized vehicle, STEM Academy For Young Kids is not responsible for any property left at the Camp or on the motorized vehicle.

I also understand that there will be specific and non-negotiable times for the departure and arrival of some STEM Academy For Young Kids transportation, and STEM Academy For Young Kids has the right to cancel my child(ren)’s participation in the motorized vehicle if these departure and arrival times are not respected.

I also agree that no general or limited partner, shareholder, director, officer, member, beneficiary, trustee, manager, other controlling person, investor, employee, attorney, agent, or independent contractor of STEM Academy For Young Kids (each an “Exculpated Person”) shall be personally liable for any obligation or liability of such party in connection with the Camp, and all obligations and liabilities of such party in connection with the Camp are enforceable solely against such party and such party’s assets, and not against any Exculpated Person or the assets of any Exculpated Person.

Liability Release and Indemnity Agreement:

I, on behalf of my child(ren), hereby release and forever discharge and agree to indemnify and save and hold harmless STEM Academy For Young Kids, Camp facility partners, the respective owners (direct and indirect) and each of their respective parents and affiliated and subsidiary companies, volunteers associated or affiliated with the Camp, and each of the aforementioned respective officials, owners, partners, directors, officers, employees and agents, and the other participants in the Camp (each such entity or individual being referred to as a “Released Party”), of and from any and all injuries (including personal injury, disability, dismemberment, and death), illness losses, damages, claims, liabilities, or expenses of any kind or nature (and whether accruing to me, my child(ren), my heirs, or my personal representatives) that are caused or alleged to be caused in whole or in part by the action, negligence, or failure to act by any Released Party or condition of any real or personal property, facility, or equipment of any Released Party, and that arise out of or are in any way connected with any aspect of the Camp or my child(ren)’s participation therein or attendance thereat.

I acknowledge that, in the event of any breach by STEM Academy For Young Kids, or any third party, the damage, if any, caused me or my child(ren) thereby will not be irreparable or otherwise sufficient to entitle me or him/her/them to seek injunctive or other equitable relief, and my child(ren) and I will be strictly limited to the right, if any, to recover damages in an action at law. Neither my child(ren) nor I will have either the right to rescind or terminate this waiver and release or any of STEM Academy For Young Kids’s rights hereunder, or the right to enjoin the production, exhibition, or other exploitation of my child(ren)’s name, voice, and likeness, or any subsidiary or allied rights with respect thereto.

Severability of Provisions:

I have carefully read the entirety of this waiver and release and agree to all its terms and conditions. I represent that I am the parent, legal guardian or empowered representative of the minor child(ren) in the registration form with the authority to give this waiver and release, and I hereby agree that both my child(ren) and I shall be bound hereby. I agree that the foregoing terms and conditions are intended to be as broad and inclusive as is permitted by law, and any terms and conditions set forth herein found by a court to be void or unenforceable shall not affect the validity or enforceability of any other terms and conditions. This waiver and release will inure to the benefit of and will be binding upon both my, my child(ren)’s, STEM Academy For Young Kids’s respective affiliates, successors, licensees, assigns, heirs, and representatives. The validity, construction and enforceability of this waiver and release shall be governed by, and construed and interpreted in accordance with NJ State Law.

Conclusion :

I have carefully read the entirety of this waiver and release and agree to all its terms and conditions. Knowing all of these facts and in consideration for your accepting my child(ren)’s enrollment form/online registration and for being allowed to participate in the Camp, I, for myself, my child(ren) attending the camp, and anyone else who may claim on me or my child(ren)’s behalf (“I”) hereby agree that neither STEM Academy For Young Kids and/or the schools or facilities that host the Camp, are responsible for accidents, injuries, and/or medical or dental expenses arising from my child(ren)’s participation at the Camp and, accordingly, I covenant not to file suit against or otherwise sue STEM Academy For Young Kids, and waive, release, and discharge STEM Academy For Young Kids and the various schools or facilities that host the Camp, and anyone working on their behalf from any and all claims of liability or expenses of any kind or nature whatsoever arising out of or relating to my child(ren)’s participation in the Camp.

Camper 1 Name :

Camper 2 Name :

Camper 3 Name :

Parent / Empowered Representative Signature :

Printed Name :

Relationship to Minor Child :

Date :

summer camp form

Select Session :

Select Dates

BEFORE & AFTER CARE TUITION

Lunch Program at STEM $6 per meal

EMERGENCY MEDICAL RELEASE

EMERGENCY MEDICAL RELEASE

EMERGENCY CONTACT INNFORMATION - Parents notified first, next in priority.

CHILD RELEASE AUTHORIZATION

ACKNOWLEDGMENT OF WAIVER AND RELEASE

Terms of Enrollment

Office Use Only Notes

Policy on the release of children (N.J.A.C. 10:122-6.5): New Jersey Regulation

Photo Consent

ALLERGY ALERT PAGE

Name and Likeness Release:

Physical Condition:

Medical Treatment:

Camp Policies and Rules:

Assumption of Risk:

Liability Release and Indemnity Agreement:

Severability of Provisions:

Conclusion :

Policy on the release of children (N.J.A.C. 10:122-6.5):
New Jersey Regulation