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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 (robin@padoniaparkclub.com) 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!

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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