SHED Registration Form

SHED Summer Registration Form

"*" indicates required fields

Child's Name*
MM slash DD slash YYYY
MM slash DD slash YYYY
Address*
Please Circle the Program Your Child's Summer Program:*
Parent/Guardian Name*
if not applicable write N/A)
Parent/Guardian Name*
(if not applicable write N/A)
Are there documentation of a physical exam, immunization record, and lead screening on file at your child’s school?*
Dietary restrictions, allergies, chronic health conditions, etc. (if not applicable write N/A)

Please Note the Following Summer Details:

Our program this year will be FIVE days per week. SCC summer days are 8 am to 4 pm $420/week. Extended day option (4 - 6 pm) rate - $20 per day SCC is closed the week of July 4th
Please check the weeks you are signing up for.*
July 11-15 (extended day 4PM-6PM)*
July 18-22 (extended day 4PM-6PM)*
July 25-29 (extended day 4PM-6PM)*
Aug 1-5 (extended day 4PM-6PM)*
Aug 8-12 (extended day 4PM-6PM)*
Aug 15-19 (extended day 4PM-6PM)*
Aug 22-26 (extended day 4PM-6PM)*

SHED Children’s Campus TRANSPORTATION AND RELEASE AGREEMENT 2021-2021

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*

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:*
MM slash DD slash YYYY

SHED Children’s Campus FAMILY INFORMATION FORM 2021-2022

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

ADDITIONAL 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
(if not applicable write N/A)
(if not applicable write N/A)
(if not applicable write N/A)

SHED Children’s Campus FIRST AID AND EMERGENCY MEDICAL CARE, TRIPS AND PHOTOS AUTHORIZATION AND CONSENT FORM 2021-2022

Child's Name*
MM slash DD slash YYYY
Consent*
Guardian Name*
Guardian Name*

Emergency contacts (In order to be contacted)

Name*
Address*
Name*
Address*
Name*
Address*

SHED Children’s Campus 2021-2022 Child Medical Alert Form

If your child has an allergy/medical condition, please fill out this form.
Child's Name*
In helping us appropriately and safely deal with a situation involving your child in this concern, please complete the following:

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

(A minor is any person 17 years of age and younger.) 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*
Child's Name*
Consent*
MM slash DD slash YYYY
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)

SHED Children’s Campus FINANCIAL AGREEMENT FORM 2022

Consent*
Consent*
Consent*
I would like to receive a dependent care receipt for my tuition payment each month?*
MM slash DD slash YYYY

SHED Children’s Campus Summer 2022 Developmental History (Caterpillars, Monarch & Jr. Adventures ONLY)

Child's Name*
MM slash DD slash YYYY

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
Credit Card*
A down deposit of the yearly registration fee of $75 per child is required to submit the registration form.
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Expiration Date
 
Billing Address
This field is for validation purposes and should be left unchanged.