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SHED 2023 Summer Registration Form

"*" indicates required fields

Step 1 of 12

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Child's Name*
MM slash DD slash YYYY
MM slash DD slash YYYY
Address*
Please Select Your Child's Summer Program: ALL summer programs are on a waitlist - you must select your program below AND THEN select the waitlist opt-in*
Caterpillar Waitlist
To join caterpillar's waitlist please select YES below and continue to fill out the form. Thank you!
Child's Name - Caterpillar Waitlist
Please select today's date
MM slash DD slash YYYY
Monarch Waitlist
To join the Monarch summer waitlist please select YES below and continue to fill out the form. Thank you!
Child's Name - Monarch Waitlist
Please select today's date
MM slash DD slash YYYY
Summer Adventures Waitlist
To join the Summer Adventures waitlist please select YES below and continue to fill out the form. Thank you!
Child's Name - Summer Adventures Waitlist
Please select today's date
MM slash DD slash YYYY
JR Adventures Waitlist
To join the JR Adventures waitlist please select YES below and continue to fill out the form. Thank you!
Child's Name - JR Adventures Waitlist
Please select today's date
MM slash DD slash YYYY
Outdoor Adventures Waitlist
To join the Outdoor Adventures waitlist please select YES below and continue to fill out the form. Thank you!
Child's Name - Outdoor Adventures Waitlist
Please select today's date
MM slash DD slash YYYY
Team Adventures Waitlist
To join the Team Adventures waitlist please select YES below and continue to fill out the form. Thank you!
Child's Name - Team Adventures Waitlist
Please select today's date
MM slash DD slash YYYY
Parent/Guardian #1 Name*
if not applicable write N/A)
Parent/Guardian #2 Name
(if not applicable write N/A)
Parent/Guardian Name
Are there documentation of a physical exam, immunization record, and lead screening on file at your child’s school?*

Summer Sign-Up Details:

Our program this year will be FIVE days per week. SCC summer days are 8 am to 4 pm $480/week. Extended day option (4 - 6 pm) rate - $25 per day SCC is closed the week of July 4th. Please first select the weeks your child will attend and then select any extended day options you will need.
July 10 - 14
July 17 - 21
July 24 - 28
July 31 - August 4
August 7 - 11
August 14 - 18
August 21 - 25

Extended Day Sign-Up

July 10-14 (extended day 4PM-6PM)*
July 17-21 (extended day 4PM-6PM)*
July 24-28 (extended day 4PM-6PM)*
Jul 31 - Aug 4 (extended day 4PM-6PM)*
Aug 7-11 (extended day 4PM-6PM)*
Aug 14-18 (extended day 4PM-6PM)*
Aug 21-25 (extended day 4PM-6PM)*
MM slash DD slash YYYY

SHED Children’s Campus TRANSPORTATION AND RELEASE AGREEMENT 2023-2024

RELEASE INFORMATION I give my permission for my child to be released from SHED Children’s Campus at the end of the day to my spouse and/or to the following people. If no one other than you or your spouse is authorized, please indicate by writing NO ONE next to the NAME.
Full Name
Full Name
Full Name
(If you filled in this line, please speak with one of the directors.) I understand that unless otherwise notified, SHED Children’s Campus shall assume that all natural or adoptive parents or legal guardians of the enrolled child or children shall have equal access to the records kept by SHED Children’s Campus regarding the enrolled child or children. I understand that unless SHED Children’s Campus is provided with a certified copy of an order from a court of competent jurisdiction which expressly states otherwise, either natural or adoptive parent or legal guardian may visit or pick up the enrolled child or children on an unrestricted basis during the normal hours of operation during the day. I understand that if a child is not to be released to one of his/her parents, SHED Children’s Campus must have a certified copy of the court order and a photograph of the person in our records.
Consent*
I understand that people who are listed under “Emergency Contacts” (next page) are authorized by me to pick up my child at SHED Children’s Campus in an “emergency” situation.

I understand that any other transportation requests must be stated in writing and maintained in the child’s file or the above plan must be implemented. This permission is valid from date of signature to the end of that program year.

I understand that SHED Children’s Campus will assume full responsibility for my child from the time he/she arrives
at the program until my child leaves the program according to the written instructions for departure.

Transportation

My child will arrive & be picked up by parent/guardian: Yes / No*
(if not applicable write N/A)
If there is an alternative drop off/pick up at any point, I understand that I need to call or email the directors to let them know & I will also let the pick up person know to bring an ID:*
My child will use the busses contracted by SCC for swimming days & field trips:*
This is only for the following Summer Programs (Jrs/Summer Adventures, Outdoor Adventures, & Team Adventures)
MM slash DD slash YYYY

SHED Children’s Campus FAMILY INFORMATION FORM 2023-2024

Parent/Guardian*
Home Address*
Employer Address (use home address if N/A)*
Parent/Guardian
Home Address
Employer Address (use home address if N/A)
Do either of you work for a large corporation?*

ADDITIONAL FAMILY INFORMATION:

Does your child have siblings?*
Name (if not applicable write N/A)*
Name (if not applicable write N/A)*
Is there a therapist or counselor that your child sees?*
Does your child have an I.E.P.?*
If yes, please give a copy to SHED for us tp better support your child while they are with us.
(if not applicable write N/A)
(if not applicable write N/A)
(if not applicable write N/A)
MM slash DD slash YYYY

SHED Children’s Campus FIRST AID AND EMERGENCY MEDICAL CARE, TRIPS AND PHOTOS AUTHORIZATION AND CONSENT FORM 2023-2024

Child's Name*
MM slash DD slash YYYY
Consent*
I understand that the SHED Children’s Campus staff are trained in the basics of first aid and I authorize them to give my child first aid when appropriate.

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. I hereby authorize SHED Children’s Campus to call my physician and/or secure necessary medical care in case of illness or accident, to administer first aid, and to otherwise act on my behalf when I cannot be reached and/or a delay would be dangerous to the protection of my child. If I cannot be reached, I authorize SHED Children’s Campus to accompany my child in an ambulance transport to the nearest hospital for medical treatment including administration of anesthesia if surgery is advised by a physician.
Physicians Address*

Non-Parental Emergency Contacts (In order to be contacted)

Parents/Guardians will always be contacted first. Please list three DIFFERENT contacts in case parents/guardians cannot be reached.
Emergency Contact #1 Name
Address
Emergency Contact #2 Name
Address
Emergency Contact #3 Name
Address
Trips, Photos, Sunscreen and Bug Spray*
I hereby authorize SHED Children’s Campus to allow my child to participate in the following: (please check all that you agree to)
I herby authorize SHED Children's Campus to apply as needed:
By checking the box you fully agree and give SHED Children's Campus permission to apply the following: (if you do not grant permission please leave the box unchecked)

MEDICAL EMERGENCY TREATMENT:

I hereby give Kid’s Club permission to administer basic first aid and/or CPR to my child, and/or take my child, to a hospital and to secure medical treatment when I cannot be reached or when delay would be dangerous to my child’s health.
MM slash DD slash YYYY

SHED Children’s Campus 2023-2024 Child Medical Alert Form

If your child has an allergy/medical condition, please fill out this form.
In helping us appropriately and safely deal with a situation involving your child in this concern, please complete the following:
MM slash DD slash YYYY

SHED Children’s Campus FINANCIAL AGREEMENT FORM 2023

Consent*
I understand there is a non-refundable $75 registration fee per child.

I understand the registration fee only covers summer 2023 registration.

I understand the tuition for July is due May 5, 2023

I understand the tuition for August is due June 2, 2023.

SHED Children’s Campus does not bill; payment is due on the above dates. Checks should be made payable to SHED Inc. Checks can be mailed or dropped off. Payment can be made on your account on Brightwheel. Payment can also be made by credit card on our website (convenience fee will be additional).

I understand there is a $30 late fee on any tuition balances not paid by the due date.

I understand that I may only register my child for the following year if my account is up to date and clear of any debts.

I understand that I must consider my needs very carefully.
Because of ratios & guidelines, schedule changes cannot be guaranteed.

I understand that SHED Children’s Campus reserves the right to close during the day if the weather is deemed unsafe or very extreme. SCC will email families & post a message on our voicemail with opening or closing decisions.

I understand that in the event of any absences or personal vacations during the program hours, I am still responsible for fees for time reserved, not actual time spent at the Program.

I understand that all children are accepted into SHED Children’s Campus on a weekly trial basis. If SHED Children’s Campus cannot accommodate the needs of my child, SHED Children’s Campus will provide help in finding another placement.

I understand that if my child is going to be absent I need to call or email SHED Children’s Campus to let them know.
I would like to receive a dependent care receipt for my tuition payment each month?*
Consent*
I understand I need to read the Parent Handbook (can request a copy from the directors) & be responsible for following the guidelines it contains.
Consent*
I agree to adhere to the stated policies and procedures of SHED Children’s Campus and give my child permission to participate fully in this program.
MM slash DD slash YYYY

SHED, INC. Permission Form for Use of Minor's Picture On the Internet

This letter is a request for permission to use photographs of your child on the: • Official SHED, Inc. Web Site on the Internet • SHED, Inc. Facebook, Instagram & Twitter page on the Internet • In SHED, Inc. promotional literature. The images are used on the Internet to promote a wide range of activities however; the use of images is strictly controlled to best assure safety and confidentiality. Images displayed on the Internet will not be identified by name or any other identifying information. Please return the form on the back to indicate that your child's picture may or may not be used on the Internet. This permission will stay in effect until canceled by the parent or guardian. If you wish to cancel your permission and have your child's picture(s) removed, please contact the Webmaster at 978-684-5055 (Linda) and the pictures will be removed. Allow 3-5 working days for removal. Thank you for your cooperation. Linda Shottes-Bouchard Executive Director SHED Inc. 65 Phillips Street ~ Andover, MA 01810 ~ 978-684-5055 ~ FAX 978-636-4800 ~ www.shedchildrenscampus.org
Acknowledgement*
As the parent or legal guardian, I grant SHED, Inc. permission to use my child's picture on the
• Official SHED, Inc. Web Site on the Internet,
• SHED Facebook or Instagram page on the Internet
• In SHED promotional literature.
I understand that at any time, I may have my child's picture removed by contacting the SHED, Inc. Webmaster. It is
agreed that the use of my child’s photograph or photographic image shall in no way be used in any other forum other than for official SHED, Inc. business.
I hereby waive any right that I may have to inspect or approve the finished product and the advertising copy and/or other matter that may be used in connection therewith or the use to which it may be applied.
I do hereby release, acquit and forever discharge SHED, Inc., its officers, employees, attorneys, representatives, insurers and assigns from any and all demands, cause of action and/or judgments of whatsoever nature of character, past or future, known or unknown, whether in contract or in tort, whether for personal injuries, property damage, payments, fees, expenses, accounts receivable, credit, refunds, or any other monies due or to become due, or damages of any kind or nature, and whether arising from common law or statute, arising out of, in any way, the use of my photograph or photographic image for official SHED, Inc. business through its Website, Facebook page, Patch or SHED, Inc. promotional literature.
This release contains the entire agreement between the parties and shall be binding upon and inure to the benefit of the successors and assigns of the undersigned.
Child's Name*
Internet Photo Release Consent*
MM slash DD slash YYYY

SHED Children’s Campus Summer 2023 Developmental History (Caterpillars, Monarch & Jr. Adventures ONLY)

Child's Name

Personal History

Any difficulties speaking?
Does your child see a counselor/therapist?

Health

Eating

Toilet Habits

Does child indicate his/her bathroom needs:
Does child have accidents?

Sleeping Habits:

Does child still take naps?

Social Relationships:

Has child had other child care experiences?
Is your child frightened by...
Please check all that apply.
MM slash DD slash YYYY
You will only be charged the registration fee once your child is off the waitlist. Your registration fee will be received by invoice.
This field is for validation purposes and should be left unchanged.

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65 Phillips St.
Andover, MA 01810

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