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2015 Barstow Acres Children’s Center
Therapeutic Summer Day Camp Registration Form
(To be completed by Parent/Guardian)
*Please indicate which dates/weeks your child will be in attendance: __________
Today’s Date:
CHILD’S FULL NAME:
Date of Birth:
Complete Address:
Gender:
MOTHER’S NAME:
Race/Ethnicity:
Address:
Cell Phone:
Home Phone:
Work Phone:
FATHER’S NAME:
Address:
Cell Phone:
Home Phone:
Work Phone:
 Male
School Grade:
 Female
PARENTS’ EMAIL ADDRESS:
EMERGENCY CONTACT:
Address:
Cell Phone:
Home Phone:
Work Phone:
Annual Household Gross Income (check one):
___< $10k ___$10k-$20k ___$20k -$35k ___$35k-$50k ___$50k-75k ___$75k-$100k ___>$100k
# of Household Members:
If you have another child that will be attending at the same time as this child, please list their full names:
If there are any special concerns in reference to this child or any specific reason why you are sending your child to the
facility, please explain:
HEALTH INFORMATION:
Known Allergies:
Medication allergies: ____________________________
______________________________________________
Food allergies: _________________________________
______________________________________________
Other allergies (Bee or insect sting, etc.): ____________
_____________________________________________
_____________________________________________
History of Physical Impairments: (Please circle those that apply)
Diabetes
Asthma
Epilepsy
Other _____________
Date of Last Tetanus Booster: __________
Current Medications: ______________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Mental Health/Behavioral Health Issues:
If applicable, please list mental health and/or behavioral
problems your child may have: ___________________
_____________________________________________
_____________________________________________
Does your child have a current psychiatric diagnosis? Y N
If Y, please list: ________________________________
Is your child currently receiving individual or group
therapy, or being seen by a psychiatrist? Y N
If Y, please provide name and phone number:
_____________________________________________
Is your child currently on medications for psychiatric
reasons? Y N
If Y, please list name, dosage and time of day taken:
_____________________________________________
Has your child been suspended from school during the
past school year? Y N
If Y, please explain: _____________________________
_____________________________________________
Documentation of enrollment in Maryland school: Y N
Please attach required documentation to registration packet.
2015 Barstow Acres Children’s Center
Therapeutic Summer Day Camp Registration Form
(Continued)
INSURANCE INFORMATION:
Is the child covered by family medical/hospital insurance?  Yes
 No
If yes, indicate carrier or plan name: ________________________________ Group # ___________
Carrier address:
Name of Insured:
Relationship to child:
Family Doctor’s Name:
Insurance ID number:
Family Doctor’s Phone Number:
Psychiatrist’s Name:
Psychiatrist’s Phone Number:
If your child does not have health insurance, by your initial hereto, you acknowledge that the above named will be
attending Barstow Acres Children’s Center without any health insurance and you still give permission for the above
named child to attend Barstow Acres Children’s Center and will not Barstow Acres Children’s Center liable or responsible
for any medical bills that may arise. Initial ________
TERMS OF AGREEMENT:
Consent:
By completing and executing this registration form, I specifically consent to the above named child’s participation in
activities offered by Barstow Acres Children’s Center, including, but not limited to camping, ropes course, hiking, and
sporting events for the date(s) set forth above. I specifically do not want the above named child to participate in the
following activities (if excluding none, please indicate “NONE”):
______________________________________________________. Initial ________
Liability Release:
In connection with the foregoing granted consent, I, being 18 years of age or older, do on behalf of my child-participant, if said child
is not 18 years of age or older, hereby release, forever discharge and agree to hold harmless Barstow Acres Children’s Center and
the directors, employees, leaders, and agents thereof from any and all liability, claims, or demands for personal injury, sickness, or
death, as well a property damage and expenses of any nature whatsoever which may be incurred by the undersigned and/or the childparticipant that occur while said person is participating in any trip or activity sponsored by the same . Furthermore, I (or on behalf
of my child-participant if under the age of 18 years) hereby assume all risk of personal injury, sickness, death, damage and expense as
a result of participation in recreating and work activities involved therein. Further, authorization and permission is hereby given to
said organization to furnish any necessary transportation, food, and lodging for this participant. The undersigned further agrees to
hold harmless and indemnify said organization, its directors, employees, leaders, and agents, for any liability sustained by said
organization as the result of the negligent, willful, or intentional acts of said participant, including expenses incurred attendant
thereto. Initial ________
I have had sufficient opportunity to read this entire document, and by my signature hereto, I agree, on behalf of myself
and the above named child to be bound by its terms.
Signature of Parent or Guardian: ___________________________________________________
Print Name: _____________________________________________
Date: _________________
FOR OFFICE USE ONLY:
Receipt Number ____________________
Amount of Deposit Received ___________________  Check
 Cash
 Charge Date Received: _____________________
Balance Due: _________________
Amount Paid: ________________
Date Received: ____________________
Balance Due: ________________
2015 Barstow Acres Children’s Center
Therapeutic Summer Day Camp Registration Form
PHOTOGRAPH WAIVER
We are requesting permission to use photos of your child. With your permission, pictures that we
take throughout the week will appear on our website as well as brochures that will be distributed to
our clients and the general public. These photos will be put into an album that will be shown to
families interested in such services. Let us know of any hesitations you may have on this issue. Please
fill out and sign where appropriate.
We will withhold the names of the children from our website as well as any printed materials.
Please mark the appropriate box/boxes and fill in the spaces provided. We will not include pictures of
your child without your permission. If you do not wish to have your child’s picture in the brochure
or on the website please mark the appropriate place on the form.
Please feel free to call us if you have any questions or concerns at 410-414-9901.
□ I _________________________ give Barstow Acres Children’s Center permission to use photos of
my child _________________________ in their future summer camp brochures.
□ I ________________________ also give Barstow Acres Children's Center permission to use photos
of my child ___________________________ on their website found at www.childrencenter.net.
□ I _________________________ do not give Barstow Acres Children’s Center permission to use
photos of my child _________________________ in their future summer camp brochures or on
their website found at www.childrencenter.net.
Parent/Guardian Name
Parent/Guardian Signature
2015 Barstow Acres Children’s Center
Therapeutic Summer Day Camp Registration Form
Waiver and Permission to Transport Child
I, _________________________, the parent/guardian, hereby give permission to the staff of Barstow
Acres Children’s Center to transport my child _________________________ for the following:
•
•
•
Local field trips and outings that do not require public transportation or contracted bus service
In case of inclement weather and public transportation or a contracted bus is not available
Any other instance the Director deems necessary
I give permission for my child to be transported in a motor vehicle driven by a member of the Barstow
Acres Children’s Center summer camp staff. I understand that my child is expected to follow all applicable
laws regarding riding in a motor vehicle and is
expected to follow the directions provided by the driver and/or other adults.
I have read, understand, and will discuss with my child that:
(1) They will be traveling in a motor vehicle driven by an adult and they are to wear their
safety-belt while traveling;
(2) They are expected to respect each other, the vehicles they ride in, and the people they
travel with during the trip;
(3) Riding in a motor vehicle may result in personal injuries or death from wrecks,
collisions or acts by riders, other drivers, or objects; and
(4) They are to remain in their seats and not be disruptive to the driver of the vehicle.
I recognize that by participating in this activity, as with any activity involving motor vehicle
transportation, my child may risk personal injury or permanent loss. I hereby attest and verify that I have
been advised of the potential risks, that I have full knowledge of the risks involved in this activity, and
that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity,
regardless of whether I have authorized such expenses. As a condition for the transportation received, I,
for myself, my child, my executors and assigns, further agree to release and forever discharge Barstow
Acres Children’s Center’s staff and volunteers from any claim that I might have myself or that I could
bring on my child’s behalf with regard to any damages, demands or actions whatsoever, including those
based on negligence, in any manner arising out of this transportation.
I have read this entire waiver and permission form, fully understand it, and agree to be legally bound by
its terms.
Parent/Guardian Name (please print):_______________________________________
Parent/Guardian Signature: ________________________________________
Date: _________________
2015 Barstow Acres Children’s Center
Therapeutic Summer Day Camp Registration Form
CAMP INFORMATION
(please keep for your records)
Camp dates:
Monday through Friday, from 9 a.m. to 5 p.m.
June 22 - July 17, 2015
Rates: $225.00 per week. A one-time, $50.00, non-refundable registration fee applies.
Insurance will be charged any additional fees for individual and group therapy sessions.
We accept youth ages 5 to 13 years old with mild behavioral problems, adjustment disorders, social/emotional challenges
and self-esteem and confidence issues who would benefit from daily supports such as anger/stress management, social
skills training, character building exercises and positive redirection and role-modeling.
Camp activities also include field trips within the county. Activities will include storytelling, reading and journaling, arts and
crafts, board games, singing, dancing and psycho-educational group.
The children will be required to bring a bag lunch each day. Adequate water and snacks will be provided to prevent
dehydration and sickness.
NOTE TO PARENTS/GUARDIANS:
Thank you for your interest in our summer camp. We have an exciting program planned for your child, aiming to be fun and
educational while also boosting your child’s self-esteem and confidence.
Please note that while we will be providing a therapeutic component to our camp services to include character building, anger
management and social skills training, we are not equipped to handle children with severe emotional or behavioral problems. We are
able to provide services to children who respond to kindness, redirection and structure, who have mild behavioral problems. We are
not equipped to work with children who require physical, mechanical or chemical restraints. In order to meet the needs of your child,
we will conduct an interview and explain our services.
Once you have registered, we will notify you of the date, time and location of our parent’s orientation.
Please call me if you have any questions at (410) 414-9901. My cell phone is (240) 535-1433.
Sonia Hinds
APRN-BC, RPT
Executive Director
Barstow Acres Children’s Center
590 Main Street
Prince Frederick, MD 20678