Camp Registration Urban Adventure Camp Registration Contact InformationAre you enrolling more than one child?* YES NO Enrollment*Child's NameChild's BirthdateGrade Level# of Days per WeekParent or Guardian Name #1* First Last Mailing Address #1* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email #1* Enter Email Confirm Email Phone #1 Personal*Phone #1 Work*Employer #1* Job Title #1 Parent or Guardian #2*Is there a second parent or guardian? YES NO Parent or Guardian Name #2* First Last Email #2* Enter Email Confirm Email Mailing Address #2 (IF DIFFERENT THAN ADDRESS #1) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone #2 Personal*Phone #2 Work*Employer #2* Job Title #2* Pick up and Drop Off*Who will be bringing and picking up the child(ren) to and from the center each day? Please include yourself and list individuals in order of frequency. You may add up to five individuals, just click on the plus sign at the end of each row to add another row. NameRelationship to ChildContact Phone # Typical Drop-Off Time*Please let us know what time your child(ren) will be dropped off each day. We open at 8:00am. Hours : Minutes AM PM AM/PM Typical Pick-Up Time*Please let us know what time your child(ren) will be picked up each day. We close promptly at 4:30. There is a fee of $1/minute for every minute after 4:30 that the child(ren) are not picked up. Hours : Minutes AM PM AM/PM What days will your children attend?*Your child must attend at least 3 days/week. Monday Tuesday Wednesday Thursday Friday What weeks will your child(ren) attend?* June 26th-30th July 5th-7th July 10th-14th July 17th-21st July 24th-28th July 31st-August 4th August 7th-11th August 14th-18th August 21st-25th August 28th-30th Additional Information*Is there anything else we should know about your attendance plans?Emergency Contacts*Please list up to five individuals, just click on the plus sign at the end of each row to add another row. NameRelationship to ChildContact Phone #Email Billing, Tuition, and Center AgreementsTuition Payments*I understand that tuition must paid prior to my child’s attendance. I understand that I must register and pay for a minimum of two weeks of camp at a time. Invoices are emailed to the email address(es) provided. Payment may be made by ACH transaction from the link provided in the emailed invoice. Personal checks or bank checks made out to Blueprints for Learning can be mailed to the address on the invoice but must be paid and deposited prior to your child’s attendance. We do not accept credit cards for tuition payments. We do not accept cash for tuition payments. If you have concerns about making a payment or would like to request a payment schedule, please contact us to discuss your needs. A $35 fee will be assessed for bounced checks. Credit is not provided for missed days. If additional days are needed at any given time, there is space available in the classroom, and you have pre-authorized permission from the Executive Director (Crystal MaCurdy), you may bring your child to camp on an unscheduled day. Payment for the extra day will be expected prior to dropping off your child. See camp tuition rates for pricing. A registration fee of $50 is required upon enrollment. A discount of $5/day will be granted when you enroll your child for four weeks or more. You must pay for the first four weeks in full to receive the discount. Any additional weeks that you enroll your child will be charged at the discounted rate, even if you choose to pay at a later time. YES Billing address*Which address should we use for billing? Monthly invoices and receipts are sent by email. Mailing Address 1 Malling Address 2 Email 1 Email 2 Urban Adventure Camp Parent Handbook* I have read the Parent Handbook and agree to follow the program polices outlined there. The handbook is available on the Urban Adventure Camp page of our website: https://blueprints4learning.org/urban-adventure-camp-parent-handbook/ YES Tell us about your Family and your Child(ren)Family*Please describe your family, including significant people that your child relates to:Traditions*What beliefs, traditions, or holidays are important to your family? What would you like us to know about them? Would you like to share them with the program? If so, how would you like to do that?Fears and Dislikes*Please tell us about any of your child(ren)'s fears or dislikes that you would like us to know about:Comfort*What is the best way to comfort your child(ren) if he/she is upset?Additional InformationWhat else would you like us to know about your child(ren) and your family?Family Photo(s)*Please upload one or more photos of your family, pets, and close extended family to put in your child's portfolio. We use these photos with your child to help calm and reassure them when they are missing you. Drop files here or Select files Accepted file types: jpg, png, Max. file size: 32 MB, Max. files: 4. General Health InformationHealth Insurance Company* Subscriber Name(s)* Policy Number(s)* Child(ren)'s Physician or Preferred Provider* Phone # of Provider*Address of Provider* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Emergency Hospital Preference* Dental Provider*Who is your child's dentist? Phone # of Dental Provider*Child's InformationChild's Name* First Last NicknameIf your child has a nickname, indicate it here. Birth Date* Month Day Year Grade Level*Please enter a number from 0 to 7.T-Shirt SizeYouth SYouth MYouth LYouth XLAdult SAdult MAdult LAdult XLChild's Health HistoryImmunization Record (1)*Create an account on MyIR.net to access your child’s immunization records. This takes about five minutes to complete. Once you have created your account, please download and/or print out the immunization record for each child enrolled in our program and upload the file here.Accepted file types: jpg, pdf, Max. file size: 32 MB.Allergens and/or Irritants*For allergies of a serious nature that cause reactions involving hives or other potentially severe symptoms requiring the administration of medication or emergency medical response, a full Allergy Reaction Plan & Medication Orders are required from your health care provider.Allergen/IrritantIntoleranceAllergySubstitute (if applicable) Allergies*Are any of the above life threatening? YES NO Allergy Reaction Plan & Medication OrdersRequired if your child has a life-threatening allergy.Accepted file types: jpg, pdf, Max. file size: 32 MB.PreferencesPlease tell us what kinds of food your child is accustomed to eating. What does your child like? Dislike?Medical Conditions or Special Needs*Please list any medical conditions or special needs that your child has. You can add rows by clicking on the plus sign at the end of each row. If none, type n/a.Medical Condition/Special NeedName of Medication or Treatment Type Additional Information About Medical Conditions or Special Needs*Tell us more about how we can support your child's medical conditions or special needs. Type n/a if this does not apply to your child.Health Concerns*Please describe any other health concerns that our staff should be aware of.AuthorizationsPermissions*Urban Adventure Camp Staff has my permission to: Select All Take my child on walks Take photographs/video of my child for documentation purposes Take my child on the City Bus Take my child to the creek at Riverfront Park Take my child to the City Library Take my child to the City Pool Treatment Authorization*I hereby give my permission for my child, named above on this form, to be given first aid and/or CPR by a qualified staff member at Blueprints for Learning if necessary. When I cannot be contacted, I authorize and consent to medical and hospital care, treatment, and procedures for surgery, to be performed for my child by a licensed physician, health care provider, hospital, or EMT when deemed necessary or advisable to safeguard my child's health. I waive my right of informed consent to such treatment. I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment. YES NO Second Child's InformationChild's Name* First Last NicknameIf your child has a nickname, indicate it here. Child's Birth Date* Month Day Year Grade Level*Please enter a number from 0 to 7.T-Shirt SizeYouth SYouth MYouth LYouth XLAdult SAdult MAdult LAdult XLSecond Child's Health HistoryImmunization Record*Create an account on MyIR.net to access your child’s immunization records. This takes about five minutes to complete. Once you have created your account, please download and/or print out the immunization record for each child enrolled in our program and upload the file here.Accepted file types: jpg, pdf, Max. file size: 32 MB.Allergens and/or Irritants*For allergies of a serious nature that cause reactions involving hives or other potentially severe symptoms requiring the administration of medication or emergency medical response, a full Allergy Reaction Plan & Medication Orders are required from your health care provider.Allergen/IrritantIntoleranceAllergySubstitute (if applicable) Allergies*Are any of the above life threatening? YES NO Allergy Reaction Plan & Medication OrdersRequired if your child has a life-threatening allergy.Accepted file types: jpg, pdf, Max. file size: 32 MB.PreferencesPlease tell us what kinds of food your child is accustomed to eating. What does your child like? Dislike?Medical Conditions or Special Needs*Please list any medical conditions or special needs that your child has. You can add rows by clicking on the plus sign at the end of each row. If none, type n/a.Medical Condition/Special NeedName of Medication or Treatment Type Additional Information About Medical Conditions or Special Needs*Tell us more about how we can support your child's medical conditions or special needs. Type n/a if this does not apply to your child.Health Concerns*Please describe any other health concerns that our staff should be aware of.Authorizations for Second ChildPermissions*Urban Adventure Camp Staff has my permission to: Select All Take my child on walks Take photographs/video of my child for documentation purposes Take my child on the City Bus Take my child to the creek at Riverfront Park Take my child to the City Library Take my child to the City Pool Treatment Authorization*I hereby give my permission for my child, named above on this form, to be given first aid and/or CPR by a qualified staff member at Blueprints for Learning if necessary. When I cannot be contacted, I authorize and consent to medical and hospital care, treatment, and procedures for surgery, to be performed for my child by a licensed physician, health care provider, hospital, or EMT when deemed necessary or advisable to safeguard my child's health. I waive my right of informed consent to such treatment. I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment. YES NO