2013
2
013 C
lub M
ember
ship
Padonia Park Child Centers
Lakeside Day Camp
2016
Traditional Camp
Adventure Camp
option too!
Ages 5-13 June 13 to August 19, 2016
410-252-2046
www.padoniaparkclub.com
Since 1972
Limited Availability ! Reserve a place for your child today
On the grounds of Padonia Park Club Voted “Best place to swim” By Baltimore Magazine and Towson Magazine
Daily Swimming Swim Lessons Athletics
Creative Arts Drama & Music
Environmental Experiences Special Activities
Lakeside Day Camp Traditional Camp
WHO - All campers ages 5-13 WHERE - Padonia Park Club, a 30 acre countryside setting
conveniently located in Cockeysville, MD. The campus has outdoor pools, covered pavilions and much more. WHAT -
WHEN - June 13th - August 19th*. The Traditional Camp
program has schedule flexibility for children to attend one day up to 10 weeks. Camp hours are 8:30AM - 4:00PM (Mon-Fri) and includes before & after care (7-8:30AM & 4-6PM). * We are planning to have modified camp for August 15-19 based on staff availability. This will be limited
enrollment. Priority will be given to persons who were enrolled for a minimum of 2 weeks before August 15th.
Learn to Swim Program (Traditional Camp benefit)
American Red Cross provides the program that Lakeside Day Camp uses for swim instruction weeks 2 through 8. Children
are assessed and placed in levels according to the skills that they demonstrate. They will be moved through different levels throughout their summer. Completion cards will be available week 10 in the Padonia Park Club office. Progress reports will be sent home every two weeks to keep parents/guardians informed. This program is offered to the Traditional Camp only.
Adventure Camp option is for ages 9-13 years old. Full week program available for 7 weeks from June 20th-August 5th.
Camp hours are 8:30AM - 4:00PM (Mon-Fri) and includes before & after care (7-8:30AM & 4-6PM).
Daily Swimming Athletics Zip Line Archery
Marksmanship Weekly Special Events Teambuilding
Low Ropes Course Special Activities (See more information in the following pages)
Join the outdoor fun this summer
WEEKS
1
2
3
4
5
6
7
8
9
10
WEEKS
2
3
4
5
6
7
8
Jungle Rumble Obstacle
DATES MON TUES WED THURS FRI Additional Event Fees
6/13-6/17
$5
6/20-6/24
$5
6/27-7/1
$5
7/5-7/8 CLOSED
$17
7/11-7/15
7/18-7/22
$5 / $5
7/25-7/29
$17
8/1-8/5
$5
8/8-8/12
8/15-8/19
Last day of camp
$5
SL
SL
SL
SL
SL
SL SL
SL
SL
SL
SL
SL SL SL
SL SL
SL SL SL
SL SL SL
SL
Rockin’ Jump $
SL SL
SL SL SL
Space Invaders
6/20-6/24
6/27-7/1
7/5-7/8 CLOSED
7/11-7/15
7/18-7/22
7/25-7/29
8/1-8/5 Last day of
Adventure Camp
= Swim Lessons $ = Additional Cost Theme of the week SL
Adventure Camp
Wild Wild West
Padonia Olympics
Aloha Summer
Limited Availability
Traditional Camp
Video Game Party $
Color Wars
Welcome to the Jungle
Celebrate!
Under The Big Top
Pep Rally
Parent Information Meeting Wednesday, June 8, 2016 6:30pm
SL
SL Pony Rides $
Tropical Rush Wet Slide $
Rockin’ Jump
Earth Treks
Earth Treks
Cromwell Valley Picnic & Hike
Rockin’ Jump
Red Zone
Red Zone
Olympic Games
Decades of Fun Tie Dye Shirt Week $
Red Zone $
SL SL SL SL
Water
Included
Spectacular
Juggler Show
$
Dolphin Water Slide $
Eco Adventures $
Lakeside Day Camp Adventure Camp Option ages 9-13
The Adventure Camp is an option to the Traditional Camp for ages 9-13 years old. All of the Adventure Camp components support the Lakeside Day Camp commitment to provide a healthy, quality and safe program for your child. On the registration form, Parent/Guardian must place a “Y” in the Adventure Camp column and turn in all waivers and permission slips associated with Adventure Camp.
Adventure Camp is a FULL WEEK
commitment only and includes the following programming:
Zipline As part of the challenge opportunities, our zip wire allows campers to traverse a 300’ - 400’ distance through the treetops wearing a harness and safety gear. Challenge courses are wonderful tools for team work, building confidence and new skills. Our courses are always operated by trained professionals and camper participation is voluntary at all times.
Archery is known for instilling confidence, increasing attention span and building self-esteem. Any gender, size or ability can enjoy archery. Using methods set forth by USA Archery, we will teach campers basic archery skills. Campers will practice safety techniques while working on skill progression.
Marksmanship (Air Rifles) Using programming set forth by the NRA, Neighborhood Air Gun Program and Daisy Outdoor Products, we will teach campers the skills and safety applications needed to become a beginner marksmen. Marksmanship is a wonderful tool for enhancing self-confidence, self-discipline and eye-hand coordination. Our classes are taught only by trained professionals with safety and respect our foremost consideration.
Climbing Wall Fun at Earth Treks is one of the field trip destinations (fee included). In the process of climbing, participants are challenged both physically and mentally, developing trust in their team members, and confidence in themselves. Each participant will take on a level of challenge they are comfortable with.
Red Zone (laser tag), Hike at Cromwell Valley Park and Rockin’ Jump are alternating field trips for campers. (fees included). Closed toe shoes, such as sneakers, are required.
Recreational swimming is included every day in Adventure Camp. Swim lessons are not provided. If swim lessons are desired for your child,
consider alternating which camp they participate in throughout the summer.
Outdoor Skills Problem Solving & Teambuilding Athletics Challenge Course Swimming
8:30 a.m. - 4:00 p.m. Scheduled Camp Activities Camp Fees
Before & After Care Included— 7 am to 8:30 am and 4 to 6 pm
Each Child Meal Ticket
Weekly Rates $325 $33
Daily Rates $96/Day (rate for each child)
$6.75
8:30 a.m. - 4:00 p.m. Scheduled Camp Activities Camp Fees
Before & After Care Included— 7 am to 8:30 am and 4 to 6 pm
Each Child Meal Ticket
Weekly Rates $400 $33
Camp Rate Considerations
1. * Padonia Park Club members receive a discount (*). The discount applies if camper is a current year member with the member plan in effect during camp weeks registered ( i.e. Short Season members would pay non-member rate prior to July 25, 2016).
2. There are nominal fees for special performances, programming or field trips. See registration form for days and weeks requiring additional fees.
3. Camp is closed Monday July 4th. There is a 20% discount for the shortened week, as well as the weekly lunch fee is reduced to $27.
4. Week 10 has limited availability based on staffing and the hours will be modi-fied to 8:30AM-5:30PM ( adjusted fee).
Day Camp Meal Option
Ticket: $33/week or $6.75/day
Sales Tax included
Hot lunches include 12 oz.
drink; fries, apple sauce, chips, apple or carrot sticks; choice of one entree (grilled cheese, hot dog, grilled chicken, hamburger, pizza slice, chicken strips) and a dessert.
An afternoon snack and
beverage is provided.
Children also have the
opportunity to purchase snack items at the Grille in After-Camp Care. Requires additional money.
Payment options: Cash, Check (payable to Lakeside Day Camp) & credit cards accepted in the Club Office: Payment, Changes or cancellation requests: refer to Conditions of Registration.
2016 Traditional Camp (Weekly & Daily Options)
2016 Adventure Camp (Full Week Commitment Only)
Scheduled Camp Activities 8:30AM - 4PM
Before & After Care Included 7AM - 8:30AM and 4PM - 6PM
Scheduled Camp Activities 8:30AM - 4PM
Before & After Care Included 7AM - 8:30AM and 4PM - 6PM
Padonia Park Club member discount
Traditional Camp $300/week/child & $89.00/day/child * Adventure Camp is $375//week/child *
Our Camp Personnel . . . Padonia Park Club’s Lakeside Day Camp includes a fun, energetic staff dedicated to providing your child with the TOTAL summer experience. We seek staff who have a history of experience working with children; in addition, a flexible personality and a positive attitude are REQUIRED for employment. Each supervisor or counselor age 18 and over is trained in First Aid/CPR. All camp employees must complete a state and federal criminal background check. We aim to provide you with peace of mind and your child with safe,
Director, Padonia Park Child Centers // Administrative Head, Lakeside Day Camp Susan Love received her B.S. in Early Childhood Education from the University of Maryland, College Park. She has attended numerous continuing educational workshops in the field of Early Childhood Education. Susan joined Padonia Park Child Centers and Lakeside Day Camp in 2010. She is the proud mother of three sons - Joey, Jeffrey and Spencer.
Manager of Lakeside Day Camps - Pam Kohlenstein Pam has a B.S. in English from Towson University and a Master’s in Leadership in Teaching from Notre Dame. She has been teaching for 21 years, the last 14 of those at Hereford Middle School. She enjoys exercising, the beach, reading and shopping. She lives with her husband and daughter in Sparks, MD. This will be Pam’s 14th summer with Lakeside Day Camp.
Camp Manager Assistant - Elise Zanetti Elise has a B.S. in Elementary Education from Towson University and is currently working towards her Master’s in Special Education at Loyola University. She has been teaching Science for three years at Hereford Middle School and is also a middle school basketball coach. She enjoys swimming, biking and being outdoors. She has been working at Padonia Park Club since 2002 when she was hired as a swim instructor. For camp, she has been a counselor, head counselor, specialty counselor and now part of the leadership team for both camps.
Adventure Camp Manager - Steven Barth Steve has a B.A. in Elementary Education and a M.Ed. in Curriculum and Instruction from Loyola University. Steve brings to camp 9 years experience as a target sports counselor and program director with Boy Scouts of America’s summer camps. During the off-season Steve is a middle school science teacher and department chair with the Baltimore County Public Schools. In his spare time he enjoys archery, geocaching, camping, traveling, and cooking. This is Steve’s seventh summer at Lakeside Day Camp.
LAKESIDE DAY CAMP INFORMATION
1. Camper-to-counselor ratio is 8:1 for ages 5 & 6; 10:1 for ages 7 to 13. 2. Swim lessons are included for weeks 2-8 with a minimum skill level of 5 required before a child is permitted to waive the lessons. Traditional campers only.
3. For the health and safety of your child and all of the children at Lakeside Day Camp, please help us prevent the spread of contagious illnesses by keeping your child at home if he/she is ill. 4. Campers are asked to carry personal belongings in a backpack. Lakeside Day Camp will not be held responsible for loss, theft or damage to any personal items. 5. Campers should bring a bagged lunch (or lunch fee), tennis shoes, swimsuit, sunscreen, towel and a change of clothing to camp. Sandals, flip-flops and plastic shoes are not permitted for safety reasons. Campers are not permitted to bring items for trade or sale (i.e. baseball cards, string jewelry or crafts). Children should also refrain from bringing any extra personal items to camp. Electronic games are not recommended (Lakeside Day Camp cannot be responsible for lost, stolen or damaged items). All field trips require all participants to wear closed toe shoes. Adventure Campers are required to wear closed toe shoes for all adventure activities. 6. All campers and parents agree to be responsible for the cost of all medical expenses incurred for injuries sustained while using medications or allergic reaction kits for bee stings, etc. 7. Lakeside Day Camp has reserved the right to terminate participation in camp activities for major or continual rule infractions, at any time, without refund. 8. An afternoon snack and beverage will be provided. Lunch is not included in camp registration fees, but is an available option for an additional fee at The Grille by the day or week. 9. Lakeside Day Camp will not be closed due to inclement weather. 10.In the situation of inclement weather, movies rated G and PG will be shown to the campers. We will try to give advance notice. 11.Glass is not permitted on the property at any time. 12.By state law, Lakeside Day Camp cannot condone the possession or use of alcoholic beverages by minors or of illegal drugs by anyone on the property. 13.Campers must be delivered directly to a counselor and signed in at the start of each day, not merely “dropped off” at camp. Counselors must be told if a child is leaving camp early. A camper will not be released to a person who is not authorized to pick the child up through advance written permission from the child’s parent or legal guardian and must be verified by showing photo I.D. Compliance with these regulations is for the safety of your child. 14.Extended care is included in your base camp fee. Extended care begins at 7am and ends at 6pm. There will be a penalty of $1 per minute after 6pm for each child. This fee is paid at time of pick up. Repetitive late pickups could be cause for management to terminate camp participation. 15.To view the Lakeside Day Camp newsletter, go to padoniaparkclub.com, select “Lakeside Day Camp”, and click on Day Camp Newsletter. 16.Late arriving campers (arriving after 9am) should be brought to the Club Office by the main pool. A counselor will meet your child there.
Parent Information Meeting Wednesday, June 8, 2016 6:30pm Open Air Pavilion
Week # CAMP DATES PAYMENT / CHANGE / CANCELLATION
1 6/13/2016 - 6/17/2016 5:00 P.M. FRIDAY May 27th
2 6/20/2016 - 6/24/2016 5:00 P.M. FRIDAY June 3rd
3 6/27/2016 - 7/1/2016 5:00 P.M. FRIDAY June 10th
4 7/5/2016 - 7/8/2016 5:00 P.M. FRIDAY June 17th
5 7/11/2016 - 7/15/2016 5:00 P.M. FRIDAY June 24th
6 7/18/2016 - 7/22/2016 5:00 P.M. FRIDAY July 1st
7 7/25/2016 - 7/29/2016 5:00 P.M. FRIDAY July 8th
8 8/1/2016 - 8/5/2016 5:00 P.M. FRIDAY July 15th
9 8/8/2016 - 8/12/2016 5:00 P.M. FRIDAY July 22nd
10 8/15/2016 - 8/19/2016 5:00 P.M. FRIDAY July 29th
DUE DATE SCHEDULE
Refunds: Any approved refunds will be mailed in September.
We cannot apply monies if the schedule changes or cancellation requests are not received by the due dates listed above.
No refunds will be credited on any absences.
There is a $35 fee charged for any returned checks.
All campers must have had a regular physical examination by a
licensed Physician within the last 2 years and updated immunizations. We are not able to access or use prior year’s information.
Parents must carry health and accident insurance for each child in
attendance.
Forms, fees, schedule changes or cancellations must be submitted directly to the MAIN OFFICE; NOT given to the counselors. See to the left for required process of submitting changes or cancellations.
Refer a friend!
If someone registers as a new first time camper with Lakeside Day Camp and indicates your name on the application at the time of initial registration, you will receive $10 in Padonia Bucks which may be applied toward Grille purchases.
CONDITIONS OF REGISTRATION
Age requirements: At the start of camp, campers must be no younger than 5 years of age and no older than 13 years of age. Children are grouped by ages.
Campers and their parents agree to permit use of photographs taken on club property to be used for promotional purposes of the camp.
Initial or Pre-registration will only be accepted with a deposit consisting of the first week’s payment in full, picture and a completed application form indicating all camp sessions desired (pre-registration). Initial or Pre-registration must be received by the Club Office Registration for all weeks pre-registered will be recorded, but space can only be guaranteed if available and if all forms and ongoing fees are submitted no later than the required deadline dates and time listed in the “Due Date Schedule” on next page. There will be a $10 Administrative Fee for each change or cancellation made to the pre-registered schedule.
Ongoing payments will be accepted at the Padonia Park Club Office during regular operating hours, and no later than the required deadline time listed in the “Due Date Schedule” (next page); or that space will be opened up to applicants on a waiting list as of the following Saturday morning. There is also an online payment option for ongoing payments after the initial payment & registration padoniaparkclub.com/daycamp.htm) The Due Date Schedule still applies for payment deadlines to assure your child’s enrollment. If a child is registered, not paid and the space is not filled by the waiting list, you will still be responsible for the camp fees of the pre-registered time. Please do not give payments to camp counselors.
Schedule Changes and Cancellations: There will be a $10 Administrative Fee for each change or cancellation made to the pre-registered schedule. After pre-registration, requests for changes or cancellations to the child’s camp schedule must be made in writing, e-mailed ([email protected]) or faxed (443-279-1043) and received by the Club Office NO LATER THAN the required deadline dates and time listed in the “Due Date Schedule”. Otherwise, you are still responsible for the camp fees and any applicable finance charges and you will not be able to reapply monies or receive refunds. As long as in compliance with this policy and depending on space availability, the changes can be made. If you elect to e-mail or fax your schedule change request, please call to verify that the e-mail or fax was received no later than the designated deadline.
Our camp and facilities are also inspected and governed by the Baltimore County Health Department and the Maryland Department of Health and Mental Hygiene, and are personally monitored by the management of Padonia Park Child Centers. All efforts are made to exceed the licensing requirements. Camper to counselor ratios are maintained.
Lakeside Day Camp provides physical and emotional safety nets in a learning atmosphere of acceptance, encouragement and fun. The camp encourages and develops social skills, self-respect and character building, cognitive growth, emotional growth and community living skills
Lakeside Day Camp Philosophy, since 1972, strives to provide children with an enjoyable outdoor camp filled with learning and fun summer experiences stimulating the growth of each child
within a healthy, safe and quality atmosphere. We have an appreciation of individuality, cultural diversity and special needs, and realize the effectiveness of child centered, age-appropriate activities. Recent studies show that children today spend many hours per week involved with electronic media. Also, children who spend time outdoors are more likely to be happier, healthier, smarter, more cooperative, better problem-solvers and more creative. Lakeside Day Camp provides that outdoor environment for your child.
& Special Events Catering
Year-round
Indoor and Outdoor Picnic Style to Fine Dining
Expertly prepared menus . . . Tastefully presented
Social and Corporate Opportunities
We have special member plans that compliment your child’s day camp schedule.
Evening and Weekender Plus Plans!
Call today for membership information 410-252-2046
Did you know that Lakeside Day Camp
is located within the 30 countryside acres of
Padonia Park Child Centers Year round child care for children ages 3 months to Pre-K. Before & After School Care serving Mays Chapel & Pinewood.
Baltimore County Bus System transports to & from Mays Chapel Elementary School PPCC Van transportation to & from Pinewood Elementary School
Open on BCPS Professional days & most snow days!
Tra
ditio
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ste
ps
1-6
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8-1
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nal $
5 fe
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& 7
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Ste
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re-r
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ritin
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e-m
aile
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robin
@padonia
park
clu
b.c
om
) or
faxed
(443
-279-1
043);
ple
ase c
all
to v
erify
that your
e-m
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or
the f
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and p
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N
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(Ple
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itia
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Lim
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En
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***
Tie
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Date
Mo
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T
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W
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T
hurs
Fri.
C
A
WL
1
6/1
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6/1
7
C
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5 -
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W
AIV
ER
S
RE
QU
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D
OF
FIC
E
ON
LY
Week #
Adventure Camp Option
ACCOUNTING
SPECIAL EVENT FEES
Meal Ticket Projected Y or N
EMPLOYEE INITIALS
CHECK NO. CC or Cash
OFFICE USE ONLY
Ste
p
5
Adve
ntu
re C
amp O
ption C
om
ple
te s
tep
s 1
-5 &
7-1
2 F
ull
We
ek C
om
mitm
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ges 9
-13)
Ple
ase p
ut
a “Y
” in
the A
dventu
re C
am
p c
olu
mn
and o
n e
ach d
ay o
f th
at
week. If th
ere
is n
o “Y
” in
the A
dventu
re
Cam
p c
olu
mn
, your
child
will
be p
rovid
ed t
he T
raditio
nal C
am
p f
or
their c
am
p e
xperie
nce.
If you h
ave s
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Adventu
re C
am
p o
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ple
ase c
om
ple
te the follo
win
g:
I here
by a
uth
orize t
hat m
y c
hild
ma
y p
art
icip
ate
in
the
Adventu
re C
am
p (
inclu
des f
ees &
cours
es in Z
iplin
e, A
rchery
, W
all
Clim
bin
g, Laser
Ta
g, T
ram
polin
e P
ark
, H
ikin
g,
Sw
imm
ing,
Low
Ropes, A
ir R
ifle
and o
ther
outd
oor
skill
s )
. P
are
nt S
ignatu
re: _______________________________
D
ate
of sig
natu
re:
_____________
S
ee “
Lakesid
e D
ay C
am
p/R
ed Z
one/E
art
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rek/R
ockin
’ Jum
p W
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s. C
om
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te, sig
n
and r
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ttached w
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& p
erm
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com
ple
te b
oth
sid
es o
f each)
with this
Applic
atio
n &
fe
es.
Ste
p
7
Ste
p
8
Put a
“Y” in e
ach d
ay a
ttendin
g
Full Week commitment ONLY. Complete & return the attached Waiver agreements (2) with Step 7 & this form.
OF
FIC
E U
SE
ON
LY
Cam
per’s N
am
e: _
__
____
___
___
__
___
___
___
_____
__
___
__
___
___
___
_____
___
___
A
__
___
_G
__
___
_
Last
Nam
e
First N
am
e
--
LA
KE
SID
E D
AY
CA
MP
20
16
SC
HE
DU
LE
--
--F
OR
OF
FIC
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SE
ON
LY
--
Lim
ited E
nro
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Ste
p
9
Ste
p
11
Ste
p
10
1
0
Tra
nsp
ort
atio
n P
erm
issi
on S
lip/W
aive
r: I
agre
e to a
llow
my c
hild
to a
ttend t
he follo
win
g f
ield
trips that
are
schedule
d: A
dventu
re C
am
p (E
art
h T
reks, R
ed Z
one, C
rom
well
Valle
y &
Rockin
’ Jum
p)
& T
raditio
nal C
am
p
(Red Z
one &
Rockin
’ Jum
p).
Passenger
appro
ved b
usses o
r vans w
ill b
e u
sed a
s tra
nsport
atio
n.
(P
lease in
itia
l)__________
EM
ERGEN
CY M
EDIC
AL T
REATM
EN
T R
ELEASE
I
DO
/DO
NO
T (
circle
one)
auth
orize a
physic
ian o
r m
edic
al fa
cili
ty to tre
at m
y c
hild
/ward
(circle
one)
for
inju
rie
s s
usta
ined w
hile
at Lakesid
e D
ay C
am
p in t
he e
vent th
at I am
not
able
to b
e c
onta
cte
d for
the c
onsent
of tr
eatm
ent.
In
sig
nin
g this
regis
tratio
n form
belo
w,
I acknow
ledge h
avin
g r
ead a
nd u
nders
tood T
he C
onditio
ns o
f R
egis
tratio
n,
Genera
l C
am
p Info
rmatio
n a
nd the
info
rmatio
n o
n b
oth
sid
es o
f th
is form
, sta
te to t
he b
est
of m
y k
now
ledge t
hat th
e h
ealth info
rmatio
n is u
p-t
o-d
ate
and a
ccura
te a
nd a
gre
e to b
ear
full
responsib
ility
fo
r m
y c
hild
while
he/s
he is e
ngaged in
any a
ctivity o
f Lakesid
e D
ay C
am
p.
___
__
__
___
__
__
__
___
__
__
__
___
__
____
__
__
___
__
__
___
__
__
___
__
__
__
_
___
__
__
___
__
__
_
Sig
natu
re o
f acknow
ledgem
ent
and a
ccepta
nce b
y P
are
nt
or
Guard
ian
D
ate
W
elc
om
e P
acket R
eceiv
ed
F
or
Off
ice U
se O
nly
Specia
l
Event $
DATE REC.
TOTAL AMT. PAID
MEAL TICKET
$
CAMP FEES
TOTAL AMT. DUE
CLO
SE
D
Specia
l
Event $
Specia
l
Event $
Specia
l
Event $
Specia
l
Event $
Specia
l E
vent
Specia
l
Event $
Specia
l
Event $
Specia
l E
vent
Specia
l
Event $
Specia
l E
vent
Ad
ven
ture
& T
rad
itio
nal
Cam
p r
eq
uir
em
en
t: f
or
Ro
ckin
’ Ju
mp
: R
EQ
UIR
ES
ON
LIN
E W
AIV
ER
(
co
mp
lete
an
d s
en
d a
sap
) ro
ckin
jum
pto
wso
n.p
festo
re.c
om
/waiv
er
in o
rder
for
yo
ur
ch
ild
to
part
icip
ate
. F
orw
ard
waiv
er
ackn
ow
led
gem
en
t to
cam
p@
padonia
park
clu
b.c
om
Ste
p
12
**
* P
rio
rity
fo
r w
ee
k 1
0 w
ill b
e g
ive
n t
o p
ers
on
s w
ho
we
re e
nro
lled
fo
r a
min
imu
m o
f 2
we
eks b
efo
re A
ug
ust
15th
.
Ste
p
4
Child
’s last n
am
e _
____
__
____
___
___
__
___
___
___
_____
__
F
irst nam
e _
___
___
___
___
____
___
___
__
___
___
___
_
Str
eet
ad
dre
ss _
__
___
___
____
___
___
__
___
___
___
_____
___
___
__
__
P
.O. B
ox _
____
___
___
__
_____
___
C
ity _
____
___
__
___
___
__
____
___
___
_
Sta
te _
__
_____
__
Z
ip _
___
___
___
P
hon
e _
_____
___
___
__
___
___
G
rade c
om
ple
ted a
s o
f Jun
e ‘1
6 _
___
___
___
___
___
____
B
irth
da
y
/
/
A
ge _
__
__
_
Male
or
Fem
ale
Ho
w r
efe
rred to L
akesid
e
P
ostc
ard
___
_
Ba
ltim
ore
’s C
hild
__
__
F
riend _
__
___
__
___
O
ther
__
___
___
___
___
__
___
F
irst
Year
Enro
lled?
Y
/ N
C
lub
Mem
ber:
Y /
N M
em
ber
#: _
___
___
___
S
wim
Level of
cam
per
if k
no
wn:
__
__
__
__
__
___
__
__
___
P
rogra
m w
here
sw
im lessons w
ere
taken:
__
__
__
__
___
__
___
___
__
Co
de
Wo
rd _
__
__
__
__
___
__
__
___
___
__
__
___
__
_ (
to b
e u
sed
by a
nyo
ne
oth
er
tha
n p
are
nt
or
gu
ard
ian w
ho
is p
ickin
g u
p t
he
ch
ild)
PA
RE
NT
IN
FO
RM
AT
ION
P
are
nt/G
uard
ian _
____
___
____
___
___
__
___
___
___
Pare
nt/G
uard
ian _
____
___
____
___
___
__
___
___
__
Addre
ss _
___
___
___
___
_____
___
___
__
___
___
___
_
A
ddre
ss _
___
___
___
___
_____
___
___
__
___
___
___
P
ho
ne (
H)
____
___
___
__
__ P
hon
e (
W)
______
___
_
P
ho
ne (
H)
____
___
___
__
__ P
hon
e (
W)
______
___
C
ell
ph
one
__
___
___
___
____
C
ell
ph
one
__
___
___
___
_____
E-m
ail
addre
ss _
___
___
__
____
___
___
__
___
___
___
E-m
ail
addre
ss _
___
___
__
____
___
___
__
___
___
___
Ca
mp
fri
en
d r
eq
ue
st
(must be t
he s
am
e a
ge):
1 _
___________________________
_
2 _
______________________
___
_____
(
Sorr
y n
o g
uara
nte
es)
Re
mo
ve
ap
pli
ca
tio
n c
are
full
y
CA
MP
ER
HE
AL
TH
HIS
TO
RY
E
merg
ency c
onta
ct (o
ther
than p
are
nt)
___
__
___
___
_____
___
_ P
ho
ne (
H)
____
___
___
__
___ (W
) ______
___
__
___
_
Docto
r __
___
___
___
__
___
____
___
___
__
___
___
_ P
hone
__
___
___
___
___
_ D
ate
of
last ph
ysic
al exam
_____
___
___
_
M
ust
be
with
in t
he
la
st 2
ye
ars
//
Info
re
quir
ed
by s
tate
Insura
nce C
arr
ier
____
___
____
___
___
__
_
Polic
y N
um
ber
____
___
__
____
___
___
__
___
_
CA
MP
ER
IM
MU
NIZ
AT
ION
IN
FO
RM
AT
ION
T
his
in
form
ati
on
is
re
qu
ire
d b
efo
re r
eg
istr
ati
on
is
co
mp
lete
or
a c
hil
d i
s a
dm
itte
d t
o d
ay c
am
p.
P
hys
icia
n m
ay f
ax
th
e i
nfo
rma
tio
n t
o 4
43
-27
9-1
04
3.
All
cam
pers
must be c
urr
ent on a
ll im
muniz
atio
ns, see w
ww
.ED
CP
.org
(Im
muniz
ation)
1.
Pro
vid
e d
ate
(m
onth
an
d y
ear)
of
cam
per’s last te
tan
us (
or
DT
P)
shot: _
__
___
__
____
_
2.
Is the c
am
per
curr
ently e
nro
lled in a
Mary
lan
d s
choo
l, p
ub
lic o
r private
?
YE
S, pro
vid
e n
am
e o
f th
e M
ary
lan
d s
choo
l: _
__
___
_____
___
___
__
___
_
NO
, pro
vid
e a
co
py o
f im
muniz
atio
ns c
onfirm
ing that th
e c
hild
has r
ece
ived a
ll im
muniz
ations a
s r
eq
uire
d b
y t
he
Mary
lan
d D
HM
H R
ecom
mended
Ch
ildho
od Im
muniz
ation S
ch
ed
ule
. S
ee w
ww
.ED
CP
.org
(Im
muniz
ation)
for
info
rmation.
3.
Is the c
am
per
exem
pt fr
om
an
y im
muniz
ation
on m
edic
al or
relig
ious g
rounds?
YE
S, pro
vid
e a
sig
ne
d c
op
y o
f M
ary
land D
ep
art
ment of
Health a
nd M
enta
l H
yg
iene Im
muniz
ation
Cert
ific
ate
fro
m e
ither
a
license
d p
hysic
ian
in
dic
atin
g tha
t th
e im
muniz
atio
n is m
edic
ally
contr
ain
dic
ate
d,
or
the p
are
nt or
guard
ian
in
dic
ating t
hat
the
y
obje
ct to
im
muniz
ations f
or
relig
ious r
easons.
NO
H
ea
lth
In
form
ati
on
: P
rovid
e info
rmation o
n a
ny m
edic
al cond
itio
ns,
psycho
logic
al con
ditio
ns, be
ha
vio
ral co
nditio
ns,
m
edic
ations, d
ieta
ry r
estr
ictions,
alle
rgie
s, or
specia
l n
eeds th
at
we n
eed t
o b
e a
ware
of
to e
nsure
th
at
your
child
’s c
am
p
experie
nce is p
ositiv
e: _
__
____
___
___
__
___
___
___
_____
___
___
__
___
___
___
_____
___
___
__
___
___
___
_____
___
___
__
_
____
___
___
__
___
___
___
_____
___
___
__
___
___
___
_____
___
___
__
___
___
___
_____
___
___
__
___
___
___
_____
___
___
__.
(Any m
edic
atio
n to b
e a
dm
inis
tere
d a
t Lakesid
e D
ay C
am
p M
US
T b
e a
ccom
panie
d b
y a
Physic
ian’s
note
expla
inin
g d
osage)
Sc
he
du
le &
Pa
ym
en
t R
ec
eip
t: yo
u w
ill b
e s
en
t a c
on
firm
ation letter
of
all
pa
ym
ents
and
yo
ur
child
’s c
am
p s
chedu
le.
P
lease r
evie
w c
are
fully
and
call
the C
lub o
ffic
e if
there
are
an
y q
uestions. 4
10
-25
2-2
04
6
2016 L
AKESID
E D
AY C
AM
P
Ap
pli
ca
tio
n f
or
Tra
dit
ion
al
an
d A
dv
en
ture
Ca
mp
T
o r
egis
ter,
retu
rn c
om
ple
ted a
pplic
ation (
Ste
ps 1
-10),
sp
ecia
l ev
en
t w
aiv
ers
an
d p
erm
issio
n s
lip
s, an
d a
ll
pa
ym
en
ts d
ue
fo
r th
e f
irst
week o
f cam
p (
cam
p t
uit
ion
, sp
ecia
l ev
en
t fe
e,
an
d o
pti
on
al m
eal ti
cket)
. R
efe
r to
D
UE
DA
TE
SC
HE
DU
LE
an
d C
ON
DIT
ION
S O
F R
EG
IST
RA
TIO
N for
com
ple
te d
eta
ils.
R
egis
tratio
n is o
n a
first-
co
me f
irst-
serv
e b
as
is. S
ub
mit
tin
g t
his
fo
rm D
OE
S N
OT
gu
ara
nte
e a
sp
ace.
P
lease u
se a
sep
ara
te a
pplic
ation f
orm
for
each c
hild
.
Att
ac
h
RE
QU
IRE
D
Cu
rre
nt
P
ho
to
Ste
p
1 S
tep
2
Ste
p
3
Adve
ntu
re C
amper
s O
nly
Adventure Camper parents must complete and return this form with Lakeside Day Camp Waivers & Application Adve
ntu
re C
amper
s O
nly
Wai
vers
and P
erm
issi
on S
lips
>>>>>>>>> Tra
ditio
nal
& A
dve
ntu
re C
amper
s
Ch
ild’s
Na
me
___
___
__
__
___
__
__
__
__
_
DO
B: _
__
__
___
__
Tra
dit
ion
al
an
d A
dv
en
ture
Ca
mp
Re
d Z
on
e A
dv
en
ture
s (
RZ
A)
Pla
ye
r W
aiv
er
an
d P
erm
iss
ion
Sli
p
By s
ign
ing
th
is a
gre
em
en
t, y
ou
ag
ree
tha
t yo
u h
ave
re
ad a
nd
un
de
rsta
nd
th
e fo
llow
ing
sta
tem
ents
: (
1)
Yo
u a
gre
e t
o f
ollo
w a
ll p
oste
d r
ule
s
an
d in
str
uctio
ns o
f R
ZA
sta
ff.
(2
) L
ase
r T
ag
is a
ph
ysic
al a
ctivity t
ha
t, lik
e o
ther
ph
ysic
al activitie
s,
involv
es a
ris
k o
f in
jury
. O
ur
are
na
is d
imly
lit
, ha
ze-f
ille
d, a
nd f
ull
of o
bsta
cle
s,
wa
lls, p
latf
orm
s a
nd
ra
mp
s.
Ma
ny p
eo
ple
are
in
th
e a
ren
a a
t th
e s
am
e tim
e,
ofte
n m
ovin
g q
uic
kly
and
qui-
etly.
While
ou
r a
ren
a is s
up
erv
ise
d, n
o p
art
of th
e a
rena
is s
up
erv
ised
co
ntin
uou
sly
. (
3)
Yo
u a
ccep
t a
nd
assum
e a
ll ri
sk o
f in
jury
fro
m p
art
ici-
pa
tion
at
RZ
A.
(4
) Y
ou
reco
gniz
e t
ha
t m
edic
al co
nditio
ns inclu
din
g a
sth
ma
, ep
ilep
sy a
nd
seiz
ure
dis
ord
ers
an
d o
the
rs c
an b
e e
xa
ce
rba
ted
or
trig
ge
red
by L
ase
r T
ag
pla
y a
nd
all
ap
pro
pria
te c
are
sho
uld
be
ta
ke
n if
yo
u h
ave
an
y s
uch
co
nd
itio
n. (
5)
Yo
u r
ele
ase
RZ
A a
nd
its
ow
ne
rs(s
),
aff
ilia
tes, m
em
be
rs,
ma
nag
ers
an
d e
mplo
ye
es f
rom
all
cla
ims,
liab
ilitie
s a
nd losses th
at m
ay a
rise
fro
m y
ou
r p
lay o
r p
art
icip
atio
n, e
xce
pt
if a
ris-
ing
so
lely
fro
m o
ur
gro
ss n
eg
lige
nce
. (
6)
Yo
u w
ill r
ep
ort
an
y in
jury
su
sta
ine
d a
t R
ZA
as s
oon
as p
ractica
l, b
ut n
o la
ter
tha
n y
ou
r d
ep
art
ure
. (
7)
Yo
u w
ill in
de
mn
ify,
de
fend
and h
old
ha
rmle
ss R
ZA
an
d its
ow
ne
r(s),
aff
iliate
s, m
em
be
rs, m
an
ag
ers
and
em
plo
ye
es f
rom
an
y c
laim
s,
liab
ility
, su
its o
r d
am
ag
es m
ad
e,
alle
ged
or
su
ffe
red
by a
nyo
ne
arisin
g o
ut o
f yo
ur
activity o
r con
duct
at
RZ
A.
(8
) If
yo
u a
re s
ign
ing t
his
as a
pa
ren
t o
r g
ua
rdia
n o
n b
eh
alf o
f a
min
or,
yo
u a
gre
e t
o b
e b
ou
nd
by t
he
te
rms o
f th
is P
laye
r W
aiv
er
and g
ive
co
nse
nt su
ch
min
or
to p
art
icip
ate
in
activitie
s
at
RZ
A.
(9
) R
ZA
ma
y r
efu
se
ad
mis
sio
n to
& e
ject
an
yo
ne
wh
o f
ails
to
follo
w o
ur
po
ste
d r
ule
s o
r in
str
uctio
ns o
r o
the
rwis
e c
au
ses a
sa
fety
ha
z-
ard
. (
10
) I
ag
ree
to
allo
w m
y c
hild
to
be
tra
nspo
rte
d b
y p
asse
ng
er
ap
pro
ved
bus a
nd
atte
nd
th
e R
ed
Zon
e fie
ld t
rip
(s).
____
___
___
__
___
___
___
_____
___
___
__
___
___
___
_____
___
___
__
_ _
____
___
____
__
S
igna
ture
: (
if u
nd
er
18,
adult p
are
nt or
guard
ian M
US
T s
ign.
Date
Ad
ven
ture
& T
rad
itio
nal
Cam
p r
eq
uir
em
en
t: f
or
Ro
ckin
’ Ju
mp
: R
EQ
UIR
ES
ON
LIN
E W
AIV
ER
(
co
mp
lete
an
d s
en
d a
sap
)
rockin
jum
pto
wson.p
festo
re.c
om
/waiv
er
in o
rder
for
your
child
to p
art
icip
ate
. F
orw
ard
waiv
er
acknow
led
gem
ent to
cam
p@
padonia
park
clu
b.c
om
LA
KE
SID
E D
AY
CA
MP
Adve
ntu
re C
amper
s O
NLY
Part
icip
ant A
ssum
ption o
f R
isk a
nd W
aiv
er
Agre
em
ent
W
elc
om
e to o
ur
Ad
ventu
re C
am
p p
rog
ram
with L
AK
ES
IDE
DA
Y C
AM
P!
The A
dventu
re C
am
p is a
po
werf
ul outd
oor
experi
ence d
esig
ned
to f
oste
r self-d
iscovery
, confidence, te
am
wo
rk, com
munic
ation a
nd g
roup p
rocess s
kill
s. It is
a c
are
fully
str
uctu
red, gra
duate
d s
erie
s o
f in
itia
tive e
vents
incorp
ora
ting p
hysic
al, m
enta
l and
socia
l challe
nge
s. A
ctivitie
s inclu
de b
ut
are
not
lim
ited t
o
relia
nce o
n o
the
rs o
r equip
ment, c
limbin
g o
ver
obsta
cle
s, ta
rget sport
s, and
rid
ing o
n o
ur
Zip
Wire o
f heig
hts
up t
o 5
0 f
eet.
W
e a
re
confident
you w
ill fin
d it a g
reat le
arn
ing e
xperi
ence;
both
fun a
nd c
halle
ngin
g.
W
hen w
ork
ing o
utd
oors
and
leadin
g p
hysic
al activitie
s, safe
ty is o
ur
main
concern
. W
e w
ill r
egula
rly d
iscuss b
asic
rule
s o
f safe
ty a
nd
pro
vid
e th
e s
pecia
l org
aniz
ation, superv
isio
n, in
str
uction a
nd e
quip
ment yo
u n
eed to
part
icip
ate
safe
ly in c
ours
e a
ctivitie
s. It
is im
possib
le f
or
us to e
limin
ate
all
risk, how
ever,
you
r com
mitm
ent to
follo
w instr
uctions a
nd
use s
ound
pers
onal ju
dgm
ent w
ill
contr
ibute
gre
atly to y
our
well
bein
g. B
y s
ignin
g this
waiv
er,
the p
art
icip
ant
accepts
that th
ere
are
inhere
nt ri
sks a
nd
hazard
s in
adventu
re p
rogra
mm
ing a
nd a
gre
es to h
old
ha
rmle
ss C
hild
Care
Inte
rnational, L
TD
., L
akesid
e D
ay C
am
p, T
he P
ad
onia
Corp
ora
tion,
and a
ny o
f th
eir
heir
s, assig
ns o
r successors
know
n a
s L
akesid
e D
ay C
am
p.
Ple
as
e r
ea
d a
nd
sig
n t
he f
ollo
win
g a
gre
em
en
t:
I, a
s a
pa
rtic
ipant,
und
ers
tand I w
ill b
e involv
ed in a
ctivitie
s that
requir
e p
eriods o
f physic
al exert
ion, b
ala
ncin
g, h
eig
hts
(u
p t
o
20’)
, lif
ting, p
ushin
g, p
ulli
ng a
nd c
limbin
g. I
know
most activitie
s w
ill b
e o
utd
oors
where
I w
ill n
ee
d to w
atc
h f
or
slip
pery
and/o
r
uneven f
ooting, lim
bs a
nd
bra
nches, in
sects
or
anim
als
and p
ossib
le e
xposure
to e
xtr
em
e o
r in
cle
ment w
eath
er.
I
fully
und
ers
tan
d t
ha
t m
y p
hysic
al activity involv
es r
isk o
f in
jury
. I u
nders
tand
th
e r
isks m
ay inclu
de loss o
r dam
age t
o p
ers
onal pro
pert
y.
I und
ers
tand
that
I w
ill n
ot
be f
orc
ed to
do a
ny a
ctivity a
nd
that
despite a
reasonab
le p
recaution ta
ken b
y L
AK
ES
IDE
DA
Y
CA
MP
, th
at a g
uara
nte
e o
f absolu
te s
afe
ty is im
possib
le. I a
gre
e to
exerc
ise g
ood p
ers
onal ju
dgm
ent, t
o a
sk f
or
help
if
I am
concern
ed a
bo
ut m
y s
afe
ty a
nd to
be r
esponsib
le f
or
decid
ing if
a p
roposed a
ctivity is a
ppro
pria
te f
or
me. I
ha
ve lis
ted
on
th
e
Med
ical H
isto
ry P
ag
e a
nd
in
form
ed
my in
str
ucto
rs o
f an
y p
hysic
al, m
en
tal, o
r m
ed
ical co
nd
itio
ns, re
cen
t in
juri
es
, m
ed
icati
on
, a
llerg
ies o
r oth
er
consid
era
tions that
mig
ht lim
it m
y a
bili
ty to p
art
icip
ate
or
aff
ect oth
er
me
mbers
of
my g
roup. I r
ealiz
e t
hat fa
ilure
to
dis
clo
se m
y info
rmation c
ould
result in s
erio
us h
arm
to m
yself o
r oth
ers
. I a
lso s
tate
that I
am
not
unde
r, a
nd
will
not
be u
nd
er
the
influence o
f any c
hem
ical substa
nce inclu
din
g a
lcohol, m
edic
ations o
r ill
egal substa
nces.
I a
gre
e to c
om
ply
with s
afe
ty instr
uctions g
iven b
y L
AK
ES
IDE
DA
Y C
AM
P a
nd
to b
e r
esponsib
le f
or
my s
afe
ty a
nd
well
bein
g. I
agre
e to h
old
LA
KE
SID
E D
AY
CA
MP
, its D
irecto
rs, O
wners
, O
ffic
ers
, E
mplo
yees, A
gents
and
/or
Associa
tes h
arm
less f
or
an
y
accid
ents
, in
jury
, lo
ss o
f or
dam
age t
o p
ropert
y that
may o
ccur
in this
pro
gra
m.
I und
ers
tand
that
all
possib
le p
recautions a
re taken to
insure
that all
pro
gra
ms a
nd
activitie
s s
ponsore
d b
y L
AK
ES
IDE
DA
Y
CA
MP
are
condu
cte
d b
y m
atu
re a
nd q
ualif
ied p
ers
onne
l in
a s
afe
an
d r
esponsib
le m
anne
r. I volu
nta
rily
assum
e th
e r
isks o
f th
e
activitie
s a
nd
agre
e to
re
port
any inju
ries b
efo
re leavin
g the p
rem
ises.
In
th
e e
ve
nt
tha
t it b
eco
me
s n
ece
ssa
ry,
I g
ive
pe
rmis
sio
n t
o L
AK
ES
IDE
DA
Y C
AM
P t
o s
ecu
re p
rop
er
me
dic
al tr
ea
tme
nt.
I
unde
rsta
nd
that
any m
edic
al expense n
ot covere
d b
y L
AK
ES
IDE
DA
Y C
AM
P m
edic
al in
sura
nce w
ill b
e b
illed d
irectly to m
e o
r to
my
insura
nce c
om
pany.
I h
ave r
ead a
nd
unders
tand
all
mate
rials
outlin
ing th
e a
dventu
re c
ours
e, in
clu
din
g th
is w
aiv
er
and a
gre
e t
o a
bid
e b
y these
term
s. I a
m a
wa
re this
is a
waiv
er
and r
ele
ase o
f lia
bili
ty a
nd
I s
ign it
vo
lun
tari
ly.
____
___
___
__
___
___
___
_____
___
___
__
___
___
___
_____
___
___
___
____
___
___
__
___
___
___
__/_
____
___
___
S
ignatu
re o
f P
art
icip
ant
P
rinte
d N
am
e –
Part
icip
ant
D
ate
Tra
dit
ion
al
& A
dve
ntu
re C
am
pe
rs
An
d
Adve
ntu
re C
amper
s O
nly
Wai
vers
and P
erm
issi
on S
lips
Ad
ve
ntu
re C
am
pe
rs O
nly
IMP
OR
TA
NT
– P
lease b
e t
horo
ugh in p
rovid
ing t
he info
rmation r
equ
este
d.
F
ailu
re to
dis
clo
se info
rmation c
ou
ld r
esu
lt in s
eri
ous h
arm
to y
ou a
s a
part
icip
an
t in
th
is p
rogra
m. P
lease d
o n
ot fo
rget to
rea
d a
nd s
ign th
e
opposite s
ide o
f th
is s
he
et.
All
the info
rmation w
ill b
e k
ept confid
entia
l.
IF Y
OU
CH
EC
K Y
ES
TO
AN
Y Q
UE
ST
ION
S B
ELO
W, D
ES
CR
IBE
PR
OB
LE
MS
IN
DE
TA
IL O
N T
HE
RIG
HT
SID
E O
F
TH
E F
OR
M.
A
ttach a
n a
dd
itio
nal sh
eet
if n
ecessary
. C
heck o
ne
Description
1. Y
es_ N
o_
Do y
ou h
ave a
ny p
rese
nt m
edic
al pro
ble
ms o
r ph
ysic
al lim
itation
?
(
Describ
e)
2. Y
es_ N
o_
Does y
our
hea
lth p
revent
yo
u f
rom
part
icip
ating in a
ny p
hysic
al activitie
s?
3. Y
es_ N
o_
Are
yo
u takin
g a
ny p
rescription o
r no
np
rescription
medic
atio
ns?
(L
ist
all
and r
ea
sons f
or
takin
g)
4.
Yes_ N
o_
Ha
ve y
ou h
ad a
ny s
urg
eri
es o
r be
en h
ospitaliz
ed f
or
an
y r
eason?
(Describ
e a
nd g
ive a
ppro
xim
ate
date
s)
5. Y
es_ N
o_
Are
yo
u a
llerg
ic to a
ny insect bite o
r m
edic
ations?
6. Y
es_ N
o_
Do y
ou
sm
oke? (I
f so h
ow
much?)
7. Y
es_ N
o_
Do y
ou
ha
ve im
pairm
ents
of
vis
ion o
r h
earin
g?
8.
Yes_ N
o_ H
ave y
ou e
ver
been
dia
gn
osed a
s h
avin
g h
igh b
loo
d p
ressure
?
A
re y
ou c
urr
en
tly u
nder
tre
atm
ent fo
r hig
h b
lood p
ressure
?
9.
Y
es_ N
o_
D
o y
ou h
ave h
eart
murm
urs
, epis
odes o
f irre
gula
r heart
bea
t, s
hort
ness
of
bre
ath
or
chest pain
on e
xert
ion
?
10. Y
es_ N
o_
Ha
ve y
ou e
ver
been d
iagn
osed a
s b
ein
g a
t risk o
f heart
dis
ease
?
Is
th
ere
an
y h
isto
ry o
f heart
dis
ease in y
our
fam
ily?
11. Y
es_ N
o_
A
re y
ou e
ngag
ed in a
reg
ula
r pro
gra
m o
f exerc
ise?
(
Describ
e e
xerc
ise a
nd f
reque
ncy)
1
2.
Yes_ N
o_
Do y
ou h
ave a
sth
ma? (
Describe)
13.
Yes_ N
o_
Do y
ou h
ave d
iabete
s, th
yro
id tro
uble
or
oth
er
en
docrin
e p
roble
ms?
(
Describ
e h
isto
ry &
sym
pto
ms)
14. Y
es_ N
o_
H
ave y
ou h
ad o
r do y
ou h
ave u
lcers
, heart
burn
or
oth
er
inte
stin
al dis
ord
ers
?
15. Y
es_ N
o_
H
ave y
ou e
ver
had s
eiz
ure
s? (
Describe a
nd g
ive d
ate
of
last seiz
ure
)
16.
Yes_ N
o_
Do y
ou h
ave p
roble
ms w
ith y
our
neck, back, arm
s, should
ers
, a
nkle
s
or
knees th
at lim
it y
our
activitie
s? (
Describe s
ym
pto
ms a
nd lim
itation)
The d
ate
of
my last te
tan
us b
ooste
r: _
__
__
___
___
___
____
_ M
y b
irth
date
is (
MM
/DD
/YY
): _
__
___
___
__
_____
___
P
ers
on
s t
o b
e c
on
tacte
d i
n c
ase
of
se
rio
us illn
ess
or
inju
ry:
___
___
___
__
__
____
___
___
__
___
___
___
_____
__
N
am
e, A
ddre
ss, P
hon
e N
um
ber
& R
ela
tio
nship
:__
___
____
___
___
__
___
___
___
_____
___
___
__
___
___
___
_____
_
Nam
e o
f In
sura
nce C
o.:_
__
____
___
___
__
___
___
___
____ M
ed
ical In
sura
nce P
lan N
um
ber
____
__
___
___
_____
__
Required o
f pare
nts
for
Adventu
re C
am
per
for
Rockin
’ Jum
p F
ield
Trip
(T
ram
polin
e P
ark
) :
RE
QU
IRE
S O
NLIN
E W
AIV
ER
(com
ple
te a
nd s
end a
sap)
ro
ckin
jum
pto
wson.p
festo
re.c
om
/waiv
er
in o
rder
for
your
child
to p
art
icip
ate
. F
orw
ard
waiv
er
acknow
led
gem
ent to
cam
p@
padonia
park
clu
b.c
om