2015 REGISTRATION
SMITH'S CLOVE PARK
YOUTH ACTIVITY CAMP
For Ages completed: Kindergarten to 9th. Grade
Camp Dates & Time:
Dates
Time:
Extended Day:
Fee Schedule:
Monroe
Child Must Be A
Town Of Monroe
Resident
Monday July 6 th. through August 14th.
9:30A.M. to 3:00 P.M.
7:30 A.M. to 9:30 A.M. & 3:00 P.M. to 5:30 P.M.
Harriman & Kiryas Joel
Extended Day Fee
$ 170.00 for 1 child
$ 125.00 for each additional child
$ 210.00 for 1 child
$ 150.00 for each additional child
$ 2.50 per hour (not pro-rated)
Make checks payable to: M.J.P.R.C. ($25 Service Fee for Returned Checks)
Registration Location:
AT SMITH’S CLOVE PARK ACTIVITY ROOM
(Questions? Call Joe at 783-9108 Park Administration Office)
Registration Dates:
Monday – Friday
Wednesday Evenings
Saturday
June 1 to June 5
June 3 & June 10
June 6 & June 13
Parent Orientation:
Saturday
June 13
10:30 AM to 4:30 PM
6:00 PM to 8:00 PM
11:00 AM to 1:00 PM
1:00 PM to 2 PM
*** REGISTRATIONS AFTER THE AFOREMENTIONED DATES ARE SUBJECT
TO AVAILABILITY AND WILL INCUR A $25 SURCHARGE PER CHILD***
*** NO REGISTRATIONS ACCEPTED AFTER JUNE 22nd ***
Read Carefully
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All information must be completed and signed by the appropriate person. No incomplete
application will be accepted.
Up to date, Park Photo ID, PROOF OF RESIDENCY (TOWN OF MONROE) IS REQUIRED for
Village of Harriman and Kiryas Joel, Village or Town tax bill or Landlord’s Name / Proof)
No application will be accepted at any time without an updated immunization record signed by a
physician, registered nurse or doctor’s office stamp.
Illegible applications will not be processed (PLEASE PRINT)
Request for refunds, must be received by June 30th in writing.
Campers under 6 at the start of camp must be able to prove they have or will have successfully
completed kindergarten (report card or note from school).
Campers are grouped by grade completed (June of 2015).
C.I.T’S must apply as if he/she is a camper.
C.I.T. camper fees will not be refunded.
Proof of guardianship may be required.
***For Office Use***
Residency ___ Town
Payment Amount _$___________ / ____ of _____Receipt # _________
___ Village
_____Check
___ Harriman / Kiryas Joel
_____Cash
 Child will be grouped according to grade completed in June 2015
2015
SMITH'S CLOVE PARK
YOUTH ACTIVITY CAMP
APPLICATION & MEDICAL HISTORY
PLEASE PRINT
Child's Last Name: ______________________First :____________________Grade Completed by 6/15____
Family Address: ___________________________________________________________Own____Rent___
Must Reside Within the Town of Monroe
(check one)
Please Indicate (___) In front of the phone number/s the order in which we should call signatory i.e.;
1,2,3,etc. Most circumstances require that we continue to call numbers until we reach a responsible
person and not a message machine or leave a message with someone not on your list.
Child's Date of Birth: _____________________ (___) Parent’s Phone #: ______________________________
Parent's Name: ____________________________________Park ID # _______________________________
(___) Father’s Cell: ___________________________(___) Work Phone #: ____________________________
(___) Mother’s Cell: ___________________________(___) Work Phone #: ____________________________
(___) Emergency #1: _____________________________ Name: ____________________________________
(___) Emergency #2: _____________________________ Name: ____________________________________
Doctors Name: _________________________________ Doctors Phone # _____________________________
E MAIL ADDRESS: ________________________________________________________________________
(optional)
(Will be used for park event notification only)
Immunization Record: (Or attach a copy of current immunization records with stamp or signature.)
Dates:
Mumps __________________________
German Measles ___________________
Measles __________________________
Diphtheria ________________________
Poliomyelitis_______________________
Tetanus __________________________
Hepatitis _________________________
Hemophilius Influenza Type b (Hib) _________
Hepatitis b _________/_________/___________
Varicella ________________________________
Height __________ Weight ______________
_________________________________________________________or
Signature of Physician or Registered Nurse
Copy Attached
Authorized
If you are claiming an exemption you need proper documentation at registration
(Page 1)
2015
CAMP NOTES
CAMPER'S NAME (one camper only) _________________________________________Sex __M__F
First Name
GROUP (Grade Completed June 2015)
K-1
2-3
Last Name
4-5
6-7+
(CIRCLE GROUP)
Any special information about this child to help assure his/her safety: attention deficit, learning or behavioral
disorders, allergies, etc. (to be filled in by parent or guardian):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
PLEASE LIST THOSE ADULTS OTHER THAN YOURSELF OR SPOUSE WHO ARE AUTHORIZED TO
PICK UP YOUR CHILD. Any additions or deletions to this list must be made in writing on form provided.
NAME
RELATIONSHIP
PHONE NO.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
PLEASE INDICATE ONLY IF: YOUR CHILD MAY NOT BE RELEASED TO YOUR SPOUSE OR
CHILD’S OTHER PARENT OR GUARDIAN, AND/OR A CUSTODY SITUATION THAT MAY
COMPROMISE YOUR CHILD'S SAFETY.
Is this situation is court ordered? YES______
NO______
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
PERMISSION TO WALK OR BIKE HOME (if yes, child must be at least 10 yrs old and child can only
leave at the end of the camp day) (Campers who walk or bike must arrive during 9:30 check-in time)
YES______
NO______
You will also have to sign on page #4 declaring you have read procedures 1-8
____________________________________
PARENT'S/GUARDIAN'S SIGNATURE
_____________________
DATE SIGNED
(Page 2)
Please read and sign-off on the following Procedures and/Policies on page 4
1. MEDICATION PROCEDURES
(Even If This Procedure Does Not Apply, Your Signature Acknowledge You Read This)
Procedure to be followed in the event that a child requires Medication while participating in the YAC program
administered by the Monroe Joint Park Recreation Commission:
No child may carry on their person any medical substance while at the YAC Program. In the
event a child is required to ingest a medical substance that has been duly prescribed by a physician, the
following procedure must be adhered to:
A) The parent and/or guardian of the child shall personally deliver the medication together with
written instructions from the physician with respect to same, to the Medical Director. The written
instructions shall include the following information:
1) Name of medicine, 2) Reason for medicine, 3) The dosage, 4) The time, 5) Number of days
B) The medication must be in the container provided by a registered pharmacist and shall have the professional
label affixed thereto.
C) Under no circumstances is a child to keep medicine on his/her person during the YAC Program.
D) The parent or guardian must submit a written request to the YAC Medical Director to give the medicine as
directed by the physician. He/she will determine if this is something they can do.
E) Medication needs to be picked up by the parent and/or guardian of the child within three (3) Program days
after the final dosage is given and/or end of camp season.
2. PARK POLICIES AND PROCEDURE
I understand that Smith’s Clove Park’s Activity Camp is a municipal run program and operates under an Orange
County Board of Health Permit having no affiliation with the Monroe-Woodbury school system. As a result,
additional programs, policies, procedures, and mandates, which pertain to the public school system, do not
necessarily apply to this camp. I also understand that disciplinary problems or special needs, beyond your
expertise, which disrupt the quality of camp time, will be addressed with the parent. If unresolved, a child, for
their own safety and other children’s in the camp may not be permitted to finish the program.
If I have any concerns or questions, I will refer to the Parent Information pamphlet I received at registration,
talk to the director or attend the aforementioned parent orientation meeting.
3. MANDATORY MEDICAL AWARENESS INFORMATION
I, the undersigned, as parent and /or guardian of_______________________________(child’s name)
understand that the YAC Program administered by the Monroe Joint Park Recreation Commission will include
an array of both sports and recreational activities typically made available to children at summer day camps.
The kinds of activities will only be limited by the imagination of our summer counselors and staff. Due to the
nature of these activities, i.e. soccer, basketball, field hockey, dodge ball, volleyball, and the like, there is body
contact involved. These and other sporting activities may be of a competitive nature, and at times, can be
vigorous.
The undersigned, as parent, legal guardian or person having legal custody of the child, does hereby grant
permission to the Monroe Joint Park Recreation Commission, its servants or employees, to administer
emergency first aid to my child in the event of an accident.
(Page 3)
4. INCLEMENT WEATHER
The undersigned also agrees and understands that should there be inclement weather, the camp is closed. If
inclement weather happens during the camp session, my child MUST be picked up immediately. For parents
who are not in the area during the day, please make prior arrangements with someone local to have your child
picked up. Up to the minute information can be obtained throughout the day by referring to the top information
banner on our Home page at www.smithsclovepark.org. We make the final call at 9:00am.
5. INSURANCE INFORMATION (IN CASE OF AN ACCIDENT)
The undersigned is responsible, in the event of injury, to ask the Director for the proper insurance forms and it
is up to the parent/guardian to submit said forms to the insurance company in the time frame allotted. We take
out a secondary accident insurance policy for each child.
6. CAMP SHIRT
(To Be Handed Out At Registration)
CAMPER’S NAME: _______________________________
Shirt Sizes Child:
Adult:
____small ____medium ____large
____small ____medium ____large ____x large
I HAVE RECEIVED A CAMP T-SHIRT AND AM AWARE THAT THIS SHIRT OR
AN APPROVED FACSIMILE MUST BE WORN ON ALL FIELD TRIPS.
ADDITIONAL SHIRTS MAY BE PURCHASED FOR $5.00 IN THE CAMP OFFICE.
7. OFFSITE SPORTS PARTICIPATION
Dear Parents:
During the camp season, the campers will be participating in intra-camp sports. Some games during
camp are played at Smith’s Clove Park and other games may take place elsewhere; such as Rosmarin's Camp,
located on School Road in Monroe.
I am aware that my child may be asked to participate in offsite intra-camp sports on specified dates. Due to
coordinating scheduling with another camp, we often have little advanced notice. Counselors choose
participants so as to be competitive. Your child is responsible for notifying you of these dates and locations as
stated by the Activity Leader.
8. BEFORE AND AFTER EXTENDED DAY PROGRAM
I understand that this is a separate program for the YAC Camp program and as such, requires a separate
registration form (attached) to be completed prior to its use.
I, the undersigned, being the legal custodial parent/guardian of the above reference child, certify that I have
read and understand the application and have answered all questions truthfully to the best of my ability and
will abide by all policies and procedures as set forth;
____________________________________
PARENT’S/GUARDIAN’S SIGNATURE
_____________________
DATE SIGNED
(Page 4)
2015
SMITH’S CLOVE PARK
YOUTH ACTIVITY CAMP
C.I.T.’s MUST APPLY AS IF HE/SHE IS A CAMPER
C.I.T. POLICIES
(IF APPLICABLE)
1. A C.I.T. [COUNSELOR IN TRAINING] MUST BE REGISTERED IN THE CAMP PROGRAM
JUST THE SAME AS A CAMPER.
2. A C.I.T. IS A VOLUNTARY POSITION ELIGIBLE FOR COMMUNITY SERVICE HOURS.
3.
A C.I.T. MUST BE AT LEAST [14] FOURTEEN YEARS OLD AS OF THE FIRST
DAY OF CAMP.
4. A C.I.T. MUST ATTEND A MANADATORY PRE-CAMP ORIENTATION GIVEN ONE (1) TIME
ONLY.
5. A C.I.T. WILL BE ASSIGNED A SPECIFIC GROUP, BUT MAY BE SWITCHED AS
THE NEED ARISES.
6.
A C.I.T. WILL ASSIST THE COUNSELORS AND/OR STAFF THROUGHOUT THE DAY WITH
THEIR GROUPS.
7. A C.I.T. WHO DOES NOT FOLLOW PROCEDURES OR CHOOSES NOT TO VOLUNTEER ANY
LONGER WILL NEED TO RETURN TO THEIR APPROPRIATE GROUP AS A CAMPER.
8. A C.I.T. MUST BE WILLING TO ATTEND EVERY DAY FOR THE TERM OF THE
CAMP. LATENESS OR BAD ATTENDANCE COULD DETERMINE IF A C.I.T. CAN STAY IN
THE PROGRAM OR RECEIVE COMMUNITY CREDIT.
9. A C.I.T MUST DEMONSTRATE THE SAME COMMITMENT AS A COUNSELOR
10. USE OF CELL PHONES OR SOCIAL MEDIA NETWORKING DEVICES ARE PROHIBITED
11. NO REGISTRATION FEE WILL BE REFUNDED.
12. A C.I.T. 16 YEARS OR OLDER MAY REQUEST A TO BE PLACED IN THE VOLUNTEER
COUNSELOR PROGRAM AND MAY HAVE THEIR FEE WAIVED.
I have read, understand and will abide by the above policies.
________________________________
C.I.T. SIGNATURE
_____________________________________
PARENT’S SIGNATURE
Extended Day Participant Application
Completing the Extended Day Application allows us to plan; it is not a commitment
to using the program
Dear Parent/Guardian,
Welcome to the Smith’s Clove Park Extended Day Program. We offer this program as an
enhancement to our Summer Camp, albeit a separate and distinct program.
Please be aware and stress to your child that this program is not a continuation of the camp day
and as such, different rules apply. Parents must have purchased a pre-paid card of a specific
number of hours prior to your child using the program. The program is run exclusive indoors
and children are expected to temper their enthusiasm and respect the room and park equipment.
Consistent uncontrolled behavior will be reported to the parents and if persists (more than 2
reprimands) may jeopardize your use of the program.
During the program, we offer passive indoor activities such as board games, access to
computers, videos, TV, reading, foosball and table tennis. In the afternoon, we offer a light
snack around 4pm.
Parents and those authorized to drop-off and pick-up your child are expected to come into the
office/activity room, a child will not be allowed to meet you in the parking lot.
As mentioned previously, parents must have purchased a pre-paid card of a specific number of
hours prior to your child using the program. We offer 4 pre-paid options: (1) 5 hours for $12.50
(2) 10 hours for $25 (3) 32 hours for $75 and (4) 64 hours for $150. Please plan accordingly as
we will not refund unused time for cash or credit toward future hours.
The morning session starts at 7:30am and goes till 9:30am, at that time your child is escorted to
his group for morning check-in then in the afternoon, at 3:00pm he/she will be escorted to the
office/activity room till the end of extended day. Extended day ends promptly at 5:30. You may
leave your child off anytime after 7:30 and pick them up anytime before 5:30pm. Failure to
collect your child by 5:30 will result in a penalty and if continues will result in your no longer
being able to use the program.
Time is computed in 1/2-hour blocks; if you use the program for 1 hour and 10 minutes, you
will be charged for 1 1/2 hours. This is necessary, as we must maintain staffing for the whole
session. Staffing consists of: 1 on-site director and 1-2 assistants depending on the numbers of
children using the program. Each day you use the program, the director will note on your card,
the time you arrives and/or the time you pick-up at the end of the day. Please verify these times
with him/her to eliminate disputes once the card is full. You will be notified as you approach
your card’s limit, so please be prepared to purchase the additional time you feel you will need.
Please keep in mind that these guidelines are important and have been developed over the years
so as we can provide a safe, enjoyable and cost effective service to the community. We
welcome any suggestions you may have to offer to improve upon our program, but understand,
we may not be able to accommodate each individual unique circumstance.
-------------------------------------------------------------------------------------------------------------------
If you plan on using the Extended Day program, please complete the following:
Parent/Guardian Name_______________________________________________________
PRINT
Child/s Name_______________________________,_______________________________
PRINT
_________________________,____________________________,____________________
*Be advised that this information is just a guideline for us to use in anticipating how
many campers may use the program. You will not be limited to the session/s with which you
designate if your situation changes.
Cards are purchased by you the first time you use the program so please plan accordingly.
I, the undersigned, being the legal custodial parent/guardian of the above reference child/s certify that I have
read the application and will abide by all policies and procedures as set forth;
____________________________________
PARENT’S/GUARDIAN’S SIGNATURE
_____________________
DATE SIGNED