SHED Summer 2023 Registration – SHED Childrens Campus

SHED 2023 Summer Registration Form

"*" indicates required fields

Step 1 of 12

Child's Name*

First Last

Name your child likes to be called*

Birth Date*

MM slash DD slash YYYY

Summer 2023 Start Date*

MM slash DD slash YYYY

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Child's Cell Phone (if not applicable write N/A)

School*

Grade entering in Fall 2023*

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*

Caterpillars Summer – Waitlist click here and YES below!

Monarch Preschool – Summer Waitlist click here and YES below!

JR Adventures – Waitlist click here and YES below!

Summer Adventures – Waitlist click here and YES below!

Team Adventure – Waitlist click here and YES below!

Outdoor Adventures – Waitlist click here and YES below!

CREW

Caterpillar Waitlist

To join caterpillar’s waitlist please select YES below and continue to fill out the form. Thank you!

YES

Child's Name – Caterpillar Waitlist

First Last

Today's Date – 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!

YES

Child's Name – Monarch Waitlist

First Last

Today's Date – 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!

YES

Child's Name – Summer Adventures Waitlist

First Last

Today's Date -Summer Adventure 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!

YES

Child's Name – JR Adventures Waitlist

First Last

Today's Date – JR 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!

YES

Child's Name – Outdoor Adventures Waitlist

First Last

Today's Date – 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!

YES

Child's Name – Team Adventures Waitlist

First Last

Today's Date – Team Adventures Waitlist

Please select today’s date

MM slash DD slash YYYY

Parent/Guardian #1 Name*

First Last

Parent/Guardian #1 Cell Phone*

Parent/Guardian #1 Email*

Parent/Guardian #1 Business Phone*

if not applicable write N/A)

Parent/Guardian #2 Name

First Last

Parent/Guardian #2 Cell Phone

Parent/Guardian #2 Email

Parent/Guardian #2 Business Phone

(if not applicable write N/A)

if there is an emergency or my child should get sick during the day, which parent/guardian should be called first?*

Parent/Guardian Name

Are there documentation of a physical exam, immunization record, and lead screening on file at your child’s school?*

Yes

Please list any special limitations or concerns you or your child may have including: Dietary restrictions, allergies, chronic health conditions, etc. (if not applicable write N/A)

Child's Eye Color*

Childs Hair Color*

Childs Skin Color*

Height*

Weight*

Sex*

Identifying Marks (if not applicable write N/A)*

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

Enroll

July 17 – 21

Enroll

July 24 – 28

Enroll

July 31 – August 4

Enroll

August 7 – 11

Enroll

August 14 – 18

Enroll

August 21 – 25

Enroll

Extended Day Sign-Up

July 10-14 (extended day 4PM-6PM)*

Monday

Tuesday

Wednesday

Thursday

Friday

N/A

July 17-21 (extended day 4PM-6PM)*

Monday

Tuesday

Wednesday

Thursday

Friday

N/A

July 24-28 (extended day 4PM-6PM)*

Monday

Tuesday

Wednesday

Thursday

Friday

N/A

Jul 31 – Aug 4 (extended day 4PM-6PM)*

Monday

Tuesday

Wednesday

Thursday

Friday

N/A

Aug 7-11 (extended day 4PM-6PM)*

Monday

Tuesday

Wednesday

Thursday

Friday

N/A

Aug 14-18 (extended day 4PM-6PM)*

Monday

Tuesday

Wednesday

Thursday

Friday

N/A

Aug 21-25 (extended day 4PM-6PM)*

Monday

Tuesday

Wednesday

Thursday

Friday

N/A

Parent/Guardian Signature*

Date*

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

First

Phone

Relationship

Full Name

First

Phone

Relationship

Full Name

First

Phone

Relationship

If there is anyone who is not allowed to pick up, please indicate below and speak with an Administrator. THIS PERSON MAY NOT PICK UP MY CHILD (if not applicable write N/A)

(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.

I fully understand and agree to the TRANSPORTATION AND RELEASE AGREEMENT

Transportation

My child will arrive & be picked up by parent/guardian: Yes / No*

Yes

If your child will arrive or be picked up by someone other than a parent/guardian, please indicate how it will occur:

(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:*

I fully understand the terms and agree

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)

Yes, I consent my child may use the SCC busses

Parent Signature*

Today's Date*

MM slash DD slash YYYY

SHED Children’s Campus FAMILY INFORMATION FORM 2023-2024

Parent/Guardian*

First Last

Relationship to Child*

Cell Phone*

Home Phone (if not applicable write N/A)*

Home Address*

Street Address Address Line 2 City State ZIP Code

Employer (if not applicable write N/A)*

Occupation (if not applicable write N/A)*

Hours at Work (if not applicable write N/A)*

Business Phone (if not applicable write N/A)*

Business Email (if not applicable write personal email)*

Employer Address (use home address if N/A)*

Street Address Address Line 2 City ZIP Code

Parent/Guardian

First Last

Relationship to Child

Cell Phone

Home Phone (if not applicable write N/A)

Home Address

Street Address Address Line 2 City ZIP Code

Employer (if not applicable write N/A)

Occupation (if not applicable write N/A)

Hours at Work (if not applicable write N/A)

Business Phone (if not applicable write N/A)

Business Email (if not applicable write personal email)

Employer Address (use home address if N/A)

Street Address Address Line 2 City ZIP Code

Do either of you work for a large corporation?*

Yes

Who? (if not applicable write N/A)*

Which Corporation? (if not applicable write N/A)*

ADDITIONAL FAMILY INFORMATION:

How did you hear about SHED Children's Campus?*

Does your child have siblings?*

Yes

Name (if not applicable write N/A)*

First

Age (if not applicable write N/A)*

Name (if not applicable write N/A)*

First

Age (if not applicable write N/A)*

Siblings’ child care program (if not applicable write N/A)*

Program phone number (if not applicable write N/A)*

Please list any special interests or abilities your child may have: (if not applicable write N/A)*

Is there a therapist or counselor that your child sees?*

Yes

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.

Yes

Are there any medications your child takes on a regular basis? What does he/she take and why?*

(if not applicable write N/A)

Please indicate any eating or sleeping problems:*

(if not applicable write N/A)

Please list any child care or group experiences that your child has had prior to SHED Children’s Campus:*

(if not applicable write N/A)

Please describe your child’s personality:*

Please indicate what languages are spoken at home: (if not applicable write N/A)*

Is there any other information you would like us to know about your child?*

Parent/Guardian Signature

Date

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*

First Last

Date of Birth*

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.

I agree to and fully understand the following policies.

Name of Hospital*

Child’s Physician’s name:*

Physicians Phone*

Physicians Address*

Street Address Address Line 2 City State ZIP Code

Health Insurance Coverage:*

Policy #*

Child’s Allergies: (if not applicable write N/A)*

Chronic Health Conditions: (if not applicable write N/A)*

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

First Last

Relationship to Child

Phone

Address

Street Address Address Line 2 City ZIP Code

Emergency Contact #2 Name

First Last

Relationship to Child

Phone

Address

Street Address Address Line 2 City ZIP Code

Emergency Contact #3 Name

First Last

Relationship to Child

Phone

Address

Street Address Address Line 2 City ZIP Code

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)

Field trips (special permission required for bus trips)

Walks (local, library, downtown, AVIS trails, Phillips Academy Bird Sanctuary, etc.)

Photos (for SHED Children’s Campus / Kid’s Club use to release to newspapers)

Photos (for SHED Children’s Campus / Kid’s Club to use on our website & Facebook / Instagram page

I hereby authorize SHED Children’s Campus to apply sunscreen as needed

I hereby authorize SHED Children’s Campus to apply bug spray as needed

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)

Sunscreen (45 SPF)

Bug Spray (7% DEET)

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.

Parent/Guardian Signature

Date

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.

Has an Allergy/Medical Condition (if not applicable write N/A)*

In helping us appropriately and safely deal with a situation involving your child in this concern, please complete the following:

How would you like us to respond if this concern arises?(if not applicable write N/A)*

Is there anything that triggers or complicates this situation? (if not applicable write N/A)*

Is there anything that your child should avoid doing? (if not applicable write N/A)*

How do you normally handle this concern? (if not applicable write N/A)*

Are there things that you find can make the situation worse?(if not applicable write N/A)*

Are there things that you find can make the situation better? (if not applicable write N/A)*

Are there any non-emergency situations that you would prefer to be phoned by a staff member to alert you to a given situation? (if not applicable write N/A)*

What is it / Are there any medical limitations that we should be aware of? (if not applicable write N/A)*

Signature

Date

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 fully understand and agree to SHED’s following financial terms

I would like to receive a dependent care receipt for my tuition payment each month?*

Yes

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.

I agree to the following policy.

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.

I agree to the following policy.

Parent/Guardian Signature

Date

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.

I have read the following:

Child's Name*

First Last

Internet Photo Release Consent*

Yes, my child’s picture may be used

No, my child’s picture may not be used on the Internet

Parent/Guardian Signature

Date

MM slash DD slash YYYY

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

Child's Name

First Last

Personal History

Any complications at birth?

Any developmental delays (sitting, crawling, walking)?

Any difficulties speaking?

Yes

Any other languages spoken at home?

Does your child see a counselor/therapist?

Yes

For what reason?

Any other helpful information? (if not applicable write N/A)

Health

Any serious illness or hospitalization?

Any physical disabilities/limitations?

Any allergies?

Any medications given regularly?

For what?

Eating

List any eating problems: (if not applicable write N/A)

Food allergies? (if not applicable write N/A)

Favorite Foods:

Any food refused? (if not applicable write N/A)

Toilet Habits

Does child indicate his/her bathroom needs:

Yes

Sometimes

Does child have accidents?

Yes

Sometimes

Are there any specific words of which we should be aware to indicate bathroom needs?

Sleeping Habits:

Does child still take naps?

Yes

Sometimes

What time does child get up in the AM

What time does child go to bed?

What does child take to bed?

Social Relationships:

Has child had other child care experiences?

Yes

Where?

How long did he/she/they attend other program(s)?

Is your child involved in other outside activities?

How does your child relate to strangers?

What is your child’s favorite toy?

Is your child frightened by…

Please check all that apply.

Animals

Rough children

Loud noises

Storms

The dark

None of the above

Is your child frightened by something else? Please explain below:

Does your child have any pets? If yes, what kind?

How would you describe your child?

Parent Guardian Signature

Date

MM slash DD slash YYYY

Summer Enrollment Registration Fee

You will only be charged the registration fee once your child is off the waitlist. Your registration fee will be received by invoice.

Price:

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This field is for validation purposes and should be left unchanged.

SHED 2023 Summer Registration Form

Summer Sign-Up Details:

Extended Day Sign-Up

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

Transportation

SHED Children’s Campus FAMILY INFORMATION FORM 2023-2024

ADDITIONAL FAMILY INFORMATION:

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

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

MEDICAL EMERGENCY TREATMENT:

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

SHED Children’s Campus FINANCIAL AGREEMENT FORM 2023

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

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

Personal History

Health

Eating

Toilet Habits

Sleeping Habits:

Social Relationships:

Call Us To Book A Tour

We'd love to have you join us while class is in session.
Please give us a call today to schedule your tour.

Join Our Mailing List

Find Us

Programs

Explore

Get In Touch

SHED 2023 Summer Registration Form

Summer Sign-Up Details:

Extended Day Sign-Up

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

Transportation

SHED Children’s Campus FAMILY INFORMATION FORM 2023-2024

ADDITIONAL FAMILY INFORMATION:

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

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

MEDICAL EMERGENCY TREATMENT:

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

SHED Children’s Campus FINANCIAL AGREEMENT FORM 2023

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

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

Personal History

Health

Eating

Toilet Habits

Sleeping Habits:

Social Relationships:

Call Us To Book A Tour

We'd love to have you join us while class is in session. Please give us a call today to schedule your tour.

Join Our Mailing List

Find Us

Programs

Explore

Get In Touch

We'd love to have you join us while class is in session.
Please give us a call today to schedule your tour.