SHED Summer Registration Form

SHED Registration Form

"*" indicates required fields

Child's Name*

First Last

Preferred Name*

Birth Date*

Program Start Date*

Address*

Street Address Address Line 2 City ZIP / Postal Code

Home Phone*

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

School*

Grade entering in Fall 2022*

Please Circle the Program Your Child's Summer Program:*

Caterpillars Summer

Monarch Preschool Summer

Jr Adventures

Summer Adventures

Team Adventure

Outdoor Adventures

CREW

Parent/Guardian Name*

First Last

Business Phone*

if not applicable write N/A)

Cell Phone*

Email*

Parent/Guardian Name*

First Last

Business Phone*

(if not applicable write N/A)

Cell Phone*

Email*

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)*

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

July 18 - 22

July 25 - 29

Aug 1 - 5

Aug 8 - 12

Aug 15 - 19

Aug 22 - 26

July 11-15 (extended day 4PM-6PM)*

Monday

Tuesday

Wednesday

Thursday

Friday

N/A

July 18-22 (extended day 4PM-6PM)*

Monday

Tuesday

Wednesday

Thursday

Friday

N/A

July 25-29 (extended day 4PM-6PM)*

Monday

Tuesday

Wednesday

Thursday

Friday

N/A

Aug 1-5 (extended day 4PM-6PM)*

Monday

Tuesday

Wednesday

Thursday

Friday

N/A

Aug 8-12 (extended day 4PM-6PM)*

Monday

Tuesday

Wednesday

Thursday

Friday

N/A

Aug 15-19 (extended day 4PM-6PM)*

Monday

Tuesday

Wednesday

Thursday

Friday

N/A

Aug 22-26 (extended day 4PM-6PM)*

Monday

Tuesday

Wednesday

Thursday

Friday

N/A

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*

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 fully understand and agree to the TRANSPORTATION AND RELEASE AGREEMENT

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*

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:*

Yes, I consent my child may use the SCC busses

Parent Signature*

Date*

SHED Children’s Campus FAMILY INFORMATION FORM 2021-2022

Parent/Guardian*

First

Parent/Guardian*

First

Relationship to Child*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer (if not applicable write N/A)*

Address (use home address if N/A)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address (use home address if N/A)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation (if not applicable write N/A)*

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

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

Cell Phone*

Email*

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 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

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?*

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

Child's Name*

First Last

Date of Birth*

Consent*

I agree to and fully understand the following policies.

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.

Name of Hospital*

Child’s Physician’s name:*

Phone*

Physician’s address:*

Health Insurance Coverage:*

Policy #*

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

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

Guardian Name*

First

Cell Phone*

Work Phone*

Home Phone*

Guardian Name*

First

Cell Phone*

Work Phone*

Home Phone*

Emergency contacts (In order to be contacted)

Name*

First Last

Relationship to Child*

Phone*

Address*

Street Address Address Line 2 City ZIP / Postal Code

Name*

First Last

Relationship to Child*

Phone*

Address*

Street Address Address Line 2 City ZIP / Postal Code

Name*

First Last

Relationship to Child*

Phone*

Address*

Street Address Address Line 2 City ZIP / Postal Code

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*

First Last

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

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)*

What is it / Are there any medical limitations that we should be aware of? (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)*

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.

Signature*

Date*

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*

I have read the following:

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*

First Last

Consent*

Yes, my child’s picture may be used

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

Signature*

Date*

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

SHED Children’s Campus FINANCIAL AGREEMENT FORM 2022

Consent*

I fully understand and agree to SHED's following financial terms

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

I understand the registration fee covers summer

I understand the tuition for July is due May 6, 2022.

I understand the tuition for August is due June 3, 2022.

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 by credit card on our website (a convenience fee will be added).

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.

Consent*

I agree to the following policy.

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 the following policy.

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

Yes

Signature*

Date*

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

Child's Name*

First Last

Birth Date*

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

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

Does your child have any pets?*

How would you describe your child?

Signature*

Date*

Registration Fee*

Price:

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

Card Number

Expiration Date

Security Code Cardholder Name

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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SHED Registration Form