CREW Summer 2023 Registration – SHED Childrens Campus

Child's Name*

First Last

Name your child likes to be called*

Birth Date*

Summer 2023 Start Date*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

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

School*

Grade entering in Fall 2023*

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 if your 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

No

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)*

Signature*

Date*

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.

Transportation

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

Yes

No

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*

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

No

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

No

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 you may have: (if not applicable write N/A)*

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

Yes

No

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

No

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 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

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*

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

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

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

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

CAPTCHA

Comments

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

CREW Registration Form SHED 2024 Summer

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

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

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Get In Touch

CREW Registration Form SHED 2024 Summer

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

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.