FAST LANE Summer Camp
Registration Form
Child’s Name:_______________________________ Age:______ D.O.B.__/__/__
Home Phone:______________________________ Grade:Fall________________
2014
Address:__________________________ City:________________ Zip:__________
…………………………………………….........
Guardian #1’s Name:__________________________ Employer:______________
Address:__________________________ City:________________ Zip:_________
Cell Phone:_____________ Work Phone:__________ Email:_________________
…………………………………………….........
Guardian #2’s Name:__________________________ Employer:______________
Address:__________________________ City:________________ Zip:__________
Cell Phone:_____________ Work Phone:__________ Email:_________________
Primary Contact: (circle one) Guardian #1
Guardian #2
Best form of Contact :(circle one)Home Phone Cell Phone Work Phone Text Email
…………………………………………….........
Emergency Contact:(not including parent or guardian.)___________________________________
Relationship:__________________________ Home Phone:__________________
Address:_________________________ City___________________ Zip_________
Cell Phone:______________________ Work Phone:________________________
…………………………………………….........
Medical Contact/Information
Physician:______________________________Phone:_______________________
Address:_________________________ City:_________________ Zip__________
Hospital Preference:_________________________ Phone:___________________
Address:___________________________ City:______________ Zip:___________
Insurance Co:______________________ Policy #:____________ID#:__________
FAST LANE Summer Camp
Child’s Name:_______________________________ Age:______ D.O.B.__/__/__
Home Phone:______________________________ Grade:Fall________________
2014
…………………………………………….........
FAST LANE will be offering 2 registration options, Full Time and Part Time.
Full Time: Sign up for each week that your child will attend all week. You can
sign up for 1 or 13 weeks. Weekly payment s are $100.00 a week (5/27 and 6/30
only $80.00).
Part Time: Sign up for as many days as you child will attend. You can sign up for
1 or 52 days. Daily payments are $25.00 a day paid weekly.
Please check all weeks Camper will attend FAST LANE Summer Camp.
Week
5/19-5/23
5/27-5/30 No Monday
6/2-6/6
6/9-6/13
6/16-6/27
6/30-7/3 No Friday
7/7-7/11
7/14-7/18
7/21-7/25
7/28-8/1
8/4-8/8
8/11-8/15
Weekly
Fees
$100.00
$80.00
$100.00
$100.00
$100.00
$80.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
Full Time
All Week
(check each week)
Part Time
(circle needed days)
MTWTF
TWTF
MTWTF
MTWTF
MTWTF
MTWT
MTWTF
MTWTF
MTWTF
MTWTF
MTWTF
MTWTF
Payment due
by
Monday 5/19
Tuesday 5/27
Monday 6/2
Monday 6/9
Monday 6/16
Monday 6/30
Monday 7/7
Monday 7/14
Monday 7/21
Monday 7/28
Monday 8/4
Monday 8/11
Total Due
Health History
Circle all that apply.
ADD/ADHD
Asthma
Bleeding/Clotting Disorder
Chicken Pox
Diabetes
Ear Infection
Seizures
Hearing Issues
Heart Defect/Disease
Migraines
Vision Issues
Psychological Conditions
Other:______________________________________________________________
List any current or past medical treatment that would affect your child’s day at
camp:______________________________________________________________
Chronic or recurring illnesses:__________________________________________
…………………………………………….........
Allergies: Circle all that apply.
Pollen
Penicillin
Poison Oak
Bee Sting
Foods
Hay Fever
Other Insect Stings Other Drugs
List any other current allergies:_________________________________________
List any dietary restrictions:____________________________________________
…………………………………………….........
List any current routine medications (prescriptions or over the counter)
1:____________________________ Time:_________ For:____________________
2:___________________________ Time:_________ For:____________________
3:___________________________ Time:_________ For:____________________
4:___________________________ Time:_________ For:____________________
Medications to be administered at camp must be in original container
accompanied by written and signed instructions from the parents or doctor.
Campers may not carry medication at any time.
Information related to your child’s health or behavior that might be helpful to
staff:_______________________________________________________________
___________________________________________________________________
…………………………………………….........
Any reason your child can not participate in strenuous activity such as
swimming, walking, strenuous games?
Yes or No If yes please explain._________________________________________
Does your child require any special accommodations? Yes or No
If yes please explain.__________________________________________________
…………………………………………….........
I authorize the following over-the counter medications to be administered as
needed: (circle all that apply)
Ibuprofen
Neosporin
Cough Drops
Tylenol
Sun Screen
Bug Spray
Other:________________________________
…………………………………………….........
In the event my child requires medical treatment and I cannot be reached, I
hereby authorize FAST LANE staff to make arrangements to transport my child
to the physician or hospital that I have designated or the nearest
hospital/emergency medical facility. I give my consent for any and all necessary
medical care treatment for my child during this time.
_____________________________________________ _____________________
Parent/guardian Signature
Date
…………………………………………….........
Swimming/Sunscreen Information
FAST LANE Summer Camp will go swimming multiple times a week. Each child
will be required to pass a swimming test before being permitted to go into deep
water (deeper than their chest).
Please circle all that apply.
can swim without any help
is taking swimming lessons
My child…….
can swim with support
needs to stay in swallow water
cannot swim
My child has permission to take the swimming test. Yes or No
I agree to allow FAST LANE Camp Staff to put sunscreen on my child’s exposed
skin (not covered by clothing/swimming suit):
_____________________________________________ _____________________
Parent/guardian Signature
Date
…………………………………………….........
Authorized Child Pick-Up List
Contacts listed below will be allowed to pick-up your child. Photo ID is required.
All contacts under the age of 18 will need to be discussed with the FAST LANE
Director. Any one not listed will not be allowed to pick-up child. Written
consent given from guardian will be permitted for one time pick-ups.
Name:____________________ Relationship:______________ Phone:__________
Name:____________________ Relationship:______________ Phone:__________
Name:____________________ Relationship:______________ Phone:__________
Name:____________________ Relationship:______________ Phone:__________
Name:____________________ Relationship:______________ Phone:__________
…………………………………………….........
Agreement and Disclaimer
1. I give permission for my child to be transported by FAST LANE
transportation.
2. Parents must sign in and out their child every day,
3. Drop off times begins at 7:00 a.m. no child will be permitted before 7:00.
4. Pick up times end at 6:00 p.m.
5. A late fee of $5.00 for every 15 minutes will be assessed to any child picked
up after the pick-up time, beginning at 6:01. Fees will need to be paid
before the child can return to Camp. After 30 minutes of the closing, with
no communication from guardian, Law Enforcement will be contacted.
6. Payments are due Monday morning for the current week of Camp. Late
payments will result in suspension from Camp until all fees are paid.
7. I will provide a lunch and drink, in a lunch box or cooler with cold pack,
each day for my child. A fee of $5.00 per day will be assessed if my child
does not have a lunch.
8. FAST LANE or its staff is not responsible for child’s personal property.
(i.e. toys, games, game systems, cell phone, or money)
__________________________________
Parent/Guardian Signature
__________________________
Date
…………………………………………….........
Code of Conduct
Please make sure that you and your child are completely familiar with these
policies. Failure to comply with these polices may result in suspension or
termination of a child’s participation in FAST LANE Summer Camp.
1. Leaving FAST LANE Summer Camp premises or Field Trip premises.
2. Using foul language, rude, or disrespectful to staff or other participants.
3. Defacing FAST LANE or another child’s property, vehicles, or field trip
facilities.
4. Engaging in fighting.
5. Bringing or using illegal substances
6. Stealing FAST LANE or another child’s property.
7. Intentionally injuring staff or another child.
8. Refusing to remain with the group during outings.
9. Refusing to follow check in and out procedures.
10.
Refusing to stay seated in FAST LANE vehicles.
11. Throwing any objects or placing any body parts out of vehicle windows.
12.
No weapons of any kind allowed.
13.No cell phones allowed.
I have read, understand, and agree to comply with these policies:
________________________________________ ___________________________
Parent/Guardian Signature
Date
________________________________________ ___________________________
Child’s Signature
Date
…………………………………………….........
PG Movie Permission
During movie times only age apporiate movies will be shown. Some of the
Family/Disney movies we choose are PG. Please sign below allowing your child
to watch PG movies.
________________________________________ ___________________________
Parent/Guardian Signature
Date