Kaleidoscope Corner Summer Camps Registration Packet



Kaleidoscope Corner Summer Camps Registration Packet

KC Kids Summer Camps

o Theme Camps

o It’s a Small World

o Camp in the City

All information must be mailed, faxed or walked into the main office.

Mailing address: Fax: 720/424-8265

Kaleidoscope Corner Kids Camps

2409 Arapahoe Street

Denver, CO 80205

Completed Registration Check list

o Information Card

o Returning and new campers must submit a current copy of Immunizations.

o Medication Request (if applicable)

o Signed Registration Form

o Signed Cancellation/Payment Policy

o Payment of all deposits and registration fees

o Human Services authorization (if applicable)

*REGISTRATIONS WILL NOT BE ACCEPTED WITHOUT ALL OF THE ABOVE

*Helpful Summer Camp Contact numbers

Kelly A. Burdick, Camp Supervisor 720/424-8260

Camp Registration Office 720/424-8291

Camp Financial Office 720/424-8293

Camp Fax 720/424-8265

REMINDER-Campers need to bring lunch and a water bottle daily.

KC Kids Camp/It’s A Small World/Camp in the City

Registration Information

WHERE CAMP HOURS: 7:00 AM– 5:45 PM

KC KIDS Camps:

“Reality Theme” SCHOOL AGES LOCATION

Lowry 4-12 8001 E. Cedar Ave (Quebec & Lowry Blvd)

Park Hill 4-12 5050 E. 19th Ave (19th & Fairfax)

Steele 5-12 320 S Marion St. (3rd & Marion)

Sandoval 5-12 3655 Wyandot St. (37th & Wyandot)

It’s A Small World:

Steele 3-6 320 S. Marion St. (3rd & Marion)

Sandoval 3-6 3655 Wyandot St (37th & Wyandot)

Camp in the City:

Crofton 5-12 2409 Arapahoe St (24th & Arapahoe)

CAMP COSTS

KC KIDS Camps

Reality Theme: Cost per week: $175 ($140 for week 5). Register for 3 or more weeks and get a

It’s a Small World 10% discount.

CAMP in the CITY: Cost per week: $135 ($108 for week 5) There is no discount for Camp in the City.

REGISTRATION FEE: $35 for one child or $50 for family (non-refundable)

DEPOSIT: $15 per registered week, per child. This non-refundable deposit is required to reserve

space in the KC Kids Camps. Deposits will be deducted from your final tuition

payment. Full tuition must be paid by the Payment Deadline.

HOW TO REGISTER (This page must accompany your registration.)

1) PRINT your name, address and phone numbers on the Registration Form. List the children and their ages you are registering under CAMPER NAME/AGE.

2) Choose the weeks each child will attend by placing and “X” within the box that corresponds to the camp site. If your child will not attend a camp that week, leave the box unmarked.

3) Total the number of registered weeks (1-9), multiply by the deposit amount ($15/wk), plus registration fee. This total is what will be due at time of registration.

4) Total the number of weeks (1-3), (4-6), and (7-9), subtract the total DEPOSITS ($15/wk) from the TOTAL WEEKS column, and put that amount in the PAYMENT DUE column and the 10% discount (if applicable).

KC Theme and IT’S A SMALL WORLD is $175 per week. Register for 3 or more weeks, you will receive a 10% discount.

CAMP in the CITY is $135 per week. There is no discount offered for CAMP in the CITY.

NO CAMP July 4th

ALL OF THE FOLLOWING INFORMATION IS REQUIRED AT TIME OF REGISTRATION

5) Complete and sign both pages of the INFORMATION CARD.

6) Sign the SUNSCREEN AUTHORIZATION form.

7) Complete and sign the MEDICATION REQUEST form (if applicable).

8) A current copy of your child(ren)’s IMMUNIZATION RECORD is required TO REGISTER.

9) A copy of your Human Services Authorization with Kaleidoscope Corner Camp site listed as the provider is required TO REGISTER (if applicable).

Mail or bring your registration packet, along with your check, money order, or cash (exact change, please) You may also pay by VISA or MASTERCARD, use the space provided on the registration form to 2409 Arapahoe Street Denver, CO 80205.

You may fax all of your information to 720/424-8265.

Staff cannot accept registrations or payments at site

KC Summer Information Card

Parent/Guardian Information

Child Information

SPECIAL NEEDS INFORMATION

HOSPITAL INFORMATION

Movie/Media Authorization SIGN IN/OUT AUTHORIZATION

KC Summer 2008

Registration Form

Parent or Guardian Name

Address City St Zip

Home Ph Work Ph Cell Ph

Camper #1 Name/Age: _________________________________________________________________________________________

KC Kids Camp $175/week (Week 5 $140)

(Place an X within the boxes below on the corresponding camp sites)

|Registration |May 23 |May 30 |June 6 |

|deadline | | | |

|Lowry | |American |

|Ages: 4-12 |Drama Kids |Idol |

CREDIT CARD AUTHORIZATION

I authorize KC KIDS CAMP/CAMP in the CITY to deduct my payments directly from my credit card listed below. I understand by signing below, my account will be charged automatically on the PAYMENT DEADLINE for each camp that I have enrolled my child(ren).

CARD #: ____ ____ ____ ____ / ____ ____ ____ ____ / ____ ____ ____ ____ / ____ ____ ____ ____ EXP :____ ____ / ____ ____ CVV#_______

SIGNATURE DATE

KC Summer 2008

Registration Form

Camper#2 Name/Age: : _________________________________________________________________________________________

KC Kids Camp $175/week (Week 5 $140)

(Place an X within the boxes below on the corresponding camp sites)

|Registration |May 23 |May 30 |June 6 |

|deadline | | | |

|Lowry | |American |

|Ages: 4-12 |Drama Kids |Idol |

KC Kids Camp/It’s A Small World/Camp in the City

TERMS of ENROLLMENT (Please Initial)

__________ REGISTRATION DEADLINES: Please note the Registration/Cancellation Deadlines for the weeks your children will be scheduled to attend camp. Please submit registration and deposit payments and all completed paperwork by 4:00pm on or before the registration deadlines.

__________ CANCELLATION POLICY: Any cancellations must be submitted in writing by the REGISTRATION DEADLINE of the camp your child(ren) is registered to attend. Failure to do so will result in the parent/guardian being held financially responsible for that week’s payment. The $15 deposit and registration fee are non-refundable, under any circumstances.

__________ SCHEDULE CHANGES: Please submit all Schedule Changes in writing by the REGISTRATION DEADLINE for the weeks you would like to change. Weeks may be added or changed only if space is available in the requested weeks. All changes must be made through the Registration Office.

__________ CAMP CANCELLATION: KC Kids Camps reserves the right to cancel any program because of low enrollment. In the event a program is cancelled, tuition payments and deposits will be refunded or transferred to operating programs.

__________ REFUNDS: No refunds or credits for any reason will be made after final Registration Deadlines. KC Kids Camps are unable to refund or credit tuition for absences or temporary withdrawals. EXCEPTION: If a child falls ill, a doctor’s note on letterhead, stating that the child’s health will prohibit him/her from participating in camp for five or more CAMP DAYS.

__________ LATE PICK-UPS: If you do not pick up your child(ren) by 5:45 pm, you will be charged $1.00 per minute, per child. If by 6:15pm parents have not contacted us Social Services will be contacted.

__________ PAYMENT OPTIONS: All payments are due no later than the Payment Deadline. You may mail in a check, money order, or walk-in cash payments to our main office at 2409 Arapahoe Street Denver, CO 80205. Visa or MasterCard payments can be automatically charged to your credit card.

__________ HUMAN SERVICES: If you will receive financial assistance through Human Services, you must provide a WRITTEN AUTHORIZATION from your caseworker, by the REGISTRATION DEADLINE for the camp site your child(ren) will be attending. If we do not have the required information, you must either pay the full tuition or your child(ren) may not attend.

If you have any questions regarding enrollment, please call us at 720/424-8291, or visit our Registration Office at

2409 Arapahoe Street Denver, CO 80205 during the hours of 8 am – 4 pm.

SUNSCREEN AUTHORIZATION

Child(ren)’s Name:

• Parents are encouraged to apply sunscreen to their child(ren) prior to attending camp.

• Parents must provide and clearly label sunscreen with child(ren)’s name.

• Children over 4 years of age must apply sunscreen to themselves under the direct supervision of a staff member.

YES, I agree to the above guidelines regarding sunscreen. I understand that the sunscreen I provide must be labeled with my child(ren)’s name.

• KC Camp staff will apply sunscreen to my child who is under 3 years of age.

_______YES, I authorize KC camp staff to apply sunscreen while at Camps to my child who is under the age of 3. I understand that the sunscreen I provide must be labeled with my child(ren)’s name.

Listed are the necessary instructions regarding sunscreen application for my child(ren) :

SIGNATURE DATE

Please attach a copy of your childs immunization record[pic]

-----------------------

Child lives with: (Check one or more) [pic] Mother [pic] Father [pic] Other (Please Specify) _________________________________

Mother/Guardian First Name: M.I. Last Name:

Address: City State Zip____

Home Phone: Cell/Pager:

Employed By: Address : City/State/Zip

Office Phone: Email

Authorized to [ ] pick up [ ] Not able to pick

Father/Guardian First Name: M.I. Last Name:

Address: City State Zip____

Home Phone: Cell/Pager:

Employed By: Address : City/State/Zip

Office Phone: Email

Authorized to [ ] pick up [ ] Not able to pick

First Name: M.I. Last Name:

Date of Birth:____________________________ Gender: [ ] Male [ ] Female Age_________________

Ethnic group you consider the child to be a member of _______________________________________________ (needed for Federal Food Program)

[ ] Allergies Yes/No [ ]Medical Problems Yes/No [ ]Asthma Yes/No [ ]Dietary Needs Yes/No [ ]Other Yes/No

Please Explain:

Persons who are authorized to pick up my child and whom Kaleidoscope Corner may contact in the event of an emergency if parent(s) or guardian(s) cannot be reached.

Other Emergency Contact InformationOrder of Emergency Contact 1 ¡% 2 ¡% 3 ¡% (check ont(s) or guardian(s) cannot be reached.

|Other Emergency Contact Information |Order of Emergency Contact 1 □ 2 □ 3 □ (check only one) |

Name of Emergency Contact: __________________________________________ Relationship to Child: _______________________

Home Address:_____________________________________________________ City/State/Zip_______________________________

Home Phone:________________________ Work Phone__________________________ Cell/Pager#___________________________

[ ] Able to pick up [ ] Not able to pick up

|Other Emergency Contact Information |Order of Emergency Contact 1 □ 2 □ 3 □ (check only one) |

Name of Emergency Contact: __________________________________________ Relationship to Child: _______________________

Home Address:_____________________________________________________ City/State/Zip_______________________________

Home Phone:________________________ Work Phone__________________________ Cell/Pager#___________________________

[ ] Able to pick up [ ] Not able to pick up

|Other Emergency Contact Information |Order of Emergency Contact 1 □ 2 □ 3 □ (check only one) |

Name of Emergency Contact: __________________________________________ Relationship to Child: _______________________

Home Address:_____________________________________________________ City/State/Zip_______________________________

Home Phone:________________________ Work Phone__________________________ Cell/Pager#___________________________

[ ] Able to pick up [ ] Not able to pick up

Parent/Guardian Signature:_______________________________________________Date:_________________________________________

Has your child been identified as disabled? [pic] No [pic] Yes

If yes, what special accommodations or modifications are needed?

*Does your child receive special education services? [pic] No [pic] Yes

Check any of the following that apply to your child.

[pic] Learning Disabilities [pic] Speech/Language [pic] Vision

[pic] Behavioral Disorders [pic] Physical Therapy [pic] Hearing

*If my child has a disability, I will need to have a meeting with the site Program Specialist before he/she may begin the program.

Please Specify

If either “Yes” has been checked, please refer to the Special Needs Policy in your Parent Handbook

Are there any activities your child cannot participate in due to physical, social or religious reasons? [pic] No [pic] Yes

(If yes, please specify)

Personal Release Statement: I understand that there is risk of injury in any recreational or sport activity and I voluntarily assume such risk. I take full responsibility for the actions and physical condition of my child. I agree to indemnify and hold harmless the Department of Community Education and Denver Public Schools from liability, loss, cost or expense (including attorney’s fees, medical, dental and ambulance costs) that my child may incur while participating in Kaleidoscope Corner activities.

Parent’s Initials_______________________

Doctor’s Name ____________________________________________ Dentist’s Name _____________________________________________

Business Phone _____________________________________ Business Phone _____________________________________________

Address _____________________City/State/Zip_____________ Address ________________________City/State/Zip________________

Preferred Hospital: (Please mark one)

___ Denver Health Medical Center, 777 Bannock St. Denver CO 80204 Phone: 303-436-6000

___ Presbyterian/St. Luke’s Medical Center (PSL), 1719 E. 19th Ave.,Denver, CO 80218 Phone: 303-839-6000

___ The Children’s Hospital, 13123 E. 16th Ave., Aurora CO 80045 Phone: 303-861-8888

___ Rose Medical Center, 4567 E 9th Ave., Denver, CO 80220 Phone: 303-320-2121

___ Porter Adventist Hospital, 2525 Downing St., Denver CO 80205 Phone: 303-778-1955

___ St. Joseph’s Hospital, 1835 Franklin St., Denver, CO 80218 Phone: 303-866-8600

___ University of Colorado Hospital, Anschutz Campus, 12605 E 16th Ave. Aurora, CO 80045 Phone: 303-372-0000

___ Name, Address and Phone # of preferred Hospital (if not listed): _________________________________________

I do hereby authorize the above named physician to render such treatment as may be deemed necessary in an emergency for the health of the child. In the event that a parent/guardian, or alternate person named on this form cannot be reached, or if the name of a doctor, dentist or hospital has not been provided, the staff is hereby authorized to call 911 for medical assistance. The staff is also authorized to take whatever action is deemed necessary in their judgment for the health of the aforementioned child.

Parent Signature_________________________________________________________________Date____________________________________

• _____I [pic] do [pic] do not give permission for my child to appear in any media coverage approved by Kaleidoscope Corner.

• _____I give permission for my child to view [pic] G Movies [pic] PG Movies [pic] No Movies

I understand that Kaleidoscope Corner-Summer Camp is not responsible for children that walk or bus to the program site until they are signed in. Furthermore, I understand that Kaleidoscope Corner-Summer Camp is not responsible for children that walk or bus from the program site once they are signed out.

• My child may sign him/herself in to SUMMER CAMP.

• My child may sign him/herself out of SUMMER CAMP - Time to be released_____________

• My child may not sign him/herself out of SUMMER CAMP

My child may not leave by her/himself. Parent’s Initials _________________

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