Child Name: ____________________________________________
T-Shirt Size (circle one): Child S M L XL
Adult S M L
Shoe Size: _________
Please select the level of care you wish your child to receive each week of camp by marking the appropriate box. If you
do a drop in day, the staff will charge the drop in rate. Please notify the staff of cancelations or if you are in need of care
within 24 hours to avoid late or drop in fees. Please make checks out to the SYC. If you need other payment
arrangements besides the deadlines listed below, please communicate with the staff to work out a plan in writing. If you
have siblings that will be coming, the staff would like to help total the cost to insure you don’t overpay.
June Attendance:
Week #1 June 15 –June 19th
Full Time: $100 __________ (Prepaid)
Single Day (Planned & Prepaid) $20 per day __________ Sibling Rate (Planned & Prepaid) $13 per day __________
Drop In Day: $25 per day ____________
Monday
Tuesday
Wednesday
Thursday
Friday
Week #2 June 22 –June 26th
Full Time: $100 __________ (Prepaid)
Single Day (Planned and Prepaid) $20 per day __________ Sibling Rate (Planned & Prepaid) $13 per day __________
Drop In Day: $25per day ____________
Monday
Tuesday
Wednesday
Thursday
Friday
Week #3 June 29-July 2nd (CLOSED JULY 3rd)
Full Time: $80 __________ (Prepaid)
Single Day (Planned and Prepaid) $20 per day __________ Sibling Rate (Planned & Prepaid) $13 per day __________
Drop In Day: $25 per day ____________
Monday
Tuesday
Wednesday
Thursday
Friday (CLOSED)
Subtotal (Cost of care for the month) $ ____________ (Pay this amount by June 15)
July Attendance:
Week #1 July 6 –July 10th
Full Time: $100 __________ (Prepaid)
Single Day (Planned and Prepaid) $20 per day __________ Sibling Rate (Planned & Prepaid) $13 per day __________
Drop In Day: $25 per day ____________
Monday
Tuesday
Wednesday
Thursday
Friday
Week #2 July 13th – July 17th
Full Time: $100 __________ (Prepaid)
Single Day (Planned and Prepaid) $20 per day __________ Sibling Rate (Planned & Prepaid) $13 per day __________
Drop In Day: $25per day ____________
Monday
Tuesday
Wednesday
Thursday
Friday
Week #3 July 20th – July 24th
Full Time: $100 __________ (Prepaid)
Single Day (Planned and Prepaid) $20 per day __________ Sibling Rate (Planned & Prepaid) $13 per day __________
Drop In Day: $25 per day ____________
Monday
Tuesday
Wednesday
Thursday
Friday
Week #4 July 27th – July 31th
Full Time: $100 __________ (Prepaid)
Single Day (Planned and Prepaid) $20 per day __________ Sibling Rate (Planned & Prepaid) $13 per day __________
Drop In Day: $25 per day ____________
Monday
Tuesday
Wednesday
Thursday
Friday
Subtotal (Cost of care for the month) $ ____________ (Pay this amount by July 1st)
August/ September Attendance:
Week #1 August 3 –August 7th
Full Time: $100 __________ (Prepaid)
Single Day (Planned and Prepaid) $20 per day __________ Sibling Rate (Planned & Prepaid) $13 per day __________
Drop In Day: $25 per day ____________
Monday
Tuesday
Wednesday
Thursday
Friday
Week #2 August 10th – August 14th
Full Time: $100 __________ (Prepaid)
Single Day (Planned and Prepaid) $20 per day __________ Sibling Rate (Planned & Prepaid) $13 per day __________
Drop In Day: $25per day ____________
Monday
Tuesday
Wednesday
Thursday
Friday
Week #3 August 17- August 21st
Full Time: $100 __________ (Prepaid)
Single Day (Planned and Prepaid) $20 per day __________ Sibling Rate (Planned & Prepaid) $13 per day __________
Drop In Day: $25 per day ____________
Monday
Tuesday
Wednesday
Thursday
Friday
Week #4 August 24 – August 28th
Full Time: $100 __________ (Prepaid)
Single Day (Planned and Prepaid) $20 per day __________ Sibling Rate (Planned & Prepaid) $13 per day __________
Drop In Day: $25 per day ____________
Monday
Tuesday
Wednesday
Thursday
Friday
Week #4 August 31 – September 3rd (CLOSED September 4th)
Full Time: $80 __________ (Prepaid)
Single Day (Planned and Prepaid) $20 per day __________ Sibling Rate (Planned & Prepaid) $13 per day __________
Drop In Day: $25 per day ____________
Monday
Tuesday
Wednesday
Thursday
Friday (CLOSED)
Subtotal (Cost of care for the month) $ ____________ (Pay this amount by August 1st)
Cancellation Policy
If you wish to cancel all or part of your child’s registration, or change the week(s) your child is scheduled to attend, you
must inform the staff members within 24 hours of the change. By doing this you will not be charged the day you cancel.
If you do not notify the staff members in a timely manner you will be billed and obligated to pay the full tuition
regardless of your child’s attendance. Children enrolled in our program are reserving a space. The specific number of
children enrolled determines the staffing level and our budgetary guidelines. In an emergency please call us to cancel or
add a day. If you want to add a day, please notify us within 24 hours of the date. If you have an emergency that requires
the need of childcare, please let us know to try to avoid the drop in rate.
Permission Forms
Day Camp/Field Trips Permission:
I hereby approve my child’s participation in the Scio Youth Club Summer Day Program and give my consent to have my
child receive a physical exam or emergency treatment by a physician or hospital EMT staff in case of emergency. I have
read and understand the attached information, and registration packet. I further agree not to hold any SYC personnel,
volunteers, board members or the Scio School District responsible for injuries that may occur to my child while
participating. By signing below, I also give SYC permission to take my child by bus on field trips. I understand that in
order for my child to attend each field trip, I must pre-pay for the cost of care at the beginning of the month or arrange a
plan with the SYC in writing.
Child’s Name: ________________________________
Parent /Guardian Signature _____________________________________________ Date _____________
Sunscreen Permission:
In order to be in compliance with Oregon state guidelines for conducting a summer youth program, written permission
is needed for applying sunscreen to your child. We will be having many outdoor activities and the sun is sure to follow us
where we may go!
SYC staff has permission to apply sunscreen spray/lotion to (Child’s Name) ____________________________
SYC staff doesn’t have permission to apply sunscreen to (Child’s Name) _______________________________
Parent/ Guardian Signature ______________________________________________ Date ___________________
*Each child needs to provide one bottle of Banana Boat SPF 30-50 Waterproof Sunscreen (lotion or spray). Please let
us know if your child has an allergy to a specific brand or product.
Picture Release Statement:
SYC Staff has permission to use photographs taken of my child during the “Summer Program” for publications and/or
advertising.
Child’s Name _____________________________________
SYC Staff doesn’t have permission to use photographs taken of my child during the “Summer Program” for publication
and/or advertising.
Child’s Name _____________________________________
Parent/Guardian Signature ________________________________________________ Date ______________
Scio Public Library Reading Program