Summer Camp 2024 Jumpstart Preschool Camp - AGES 1 - 5 YEARS

2024 Jumpstart Preschool Summer Camp - (ages 1-5 years)

Child's Name(Required)

First Last

Birth Date(Required)

Month

Day

Year

Age as of June 1, 2024(Required)

1 years old

2 years old

3 years old

4 years old

5 years old

Primary Parent/ Caregiver Name(Required)

First Last

Relationship to child:(Required)

1st Parent/ Guardian Cell Phone(Required)

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Parent/ Caregiver's Place of Employment(Required)

Work Phone(Required)

1st Parent/ Caregiver Email(Required)

Secondary Caregiver Name

First Last

Secondary Caregiver Cell Phone

Secondary Caregiver Address

Street Address Address Line 2 City State ZIP Code

Secondary Parent/ Cargiver's Employer

Secondary Parent/ Caregiver Work Phone

EMERGENCY CONTACT /NAME OF PERSON TO CALL IF PARENTS CAN NOT BE REACHED(Required)

Emergency Contact Cell Phone(Required)

Emergency Contact Email(Required)

Emergency Contact Address(Required)

Street Address Address Line 2 City State ZIP Code

Is the emergency contact authorized to take the child from FAC?(Required)

List all other adults who are authorized to take the child from the center:

Name

First Last

Relationship

Cell Phone

Name

First Last

Relationship

Cell Phone

Name

First Last

Relationship

Cell Phone

Select weeks camper will be attending(Required)

Please visit our Summer Camp 2024 Guide (linked above) to review our 2024 Summer Camp Field Trips!

Week 1 - June 3-7 - 4-5 year olds field trip - Altitude

Week 2 - June 10-14 - 4-5 year olds field trip - Chuck E Cheese

Week 3 - June 17-21 - 4-5 year olds field trip - Maggie Moos

Week 4 - June 24-28 - 4-5 year olds field trip - Ozark Lanes

Week 5 - July 1,2,3,5 - 4-5 year olds field trip - Malco Theater

Week 6 - July 8-12 - 4-5 year olds field trip - Braums

Week 7 - July 15-19 - 4-5 year olds field trip - Gator Golf

Week 8 - July 22-26 - 4-5 year olds field trip - Ozark Nature Center

Week 9 - July 29-Aug 2 - 4-5 year olds field trip - Amazeum

Week 10 - Aug 5 - 9 - 4-5 year olds field trip - Blue Zoo

Consent(Required)

I understand that my child will be attending the field trips listed above and will be transported by the FAC buses and/or vans. I grant the Fayetteville Athletic Club team permission to transport my child to/from these locations. I also understand that I may NOT pick up my child from the field trip location(s). Please sign below.

Signature(Required)

Camper Medical Information

Allergies? (n/a if none)(Required)

Physical or Emotional Concerns Your Child May Have:

Special Food Needs?

Prescribed Diet:

Other Conditions or Comments?

Please Select All of The Following Conditions/Illnesses That Your Child Has Had:(Required)

Measels

Chicken Pox

Defective Heart

Frequent Ear Infection

Diabetes

Mumps

Whooping Cough

Sun Sensitivity

Frequent Throat Infection

ADD/ADHD

German Measels

Positive TB Test

Fainting Spells

Frequent Colds

Temper Tantrums

Hospital Emergency Room of Choice:(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

I, (mother/father/guardian), do hereby give my consent to the Director of the Child Care facility, or his/her representative, for said child to receive medical or surgical aid as may be deemed necessary and expedient by a duly licensed or recognized physician or surgeon in case of emergency when parent/guardian can not be reached. Consent is also given for the Director or his/her duly appointed representative to transport said child for emergency medical treatment, if the parents cannot be reached. Please sign below.(Required)

I give, or do not give the Director of the Kid's FACtory or his/her appointed representative, permission to give my child Acetaminophen. I understand that I will be notified if that medication has been administered(Required)

Signature(Required)

I give, or do not give the Director of the Kid's FACtory or his/her appointed representative, permission to use sunscreen/ suntan lotion on my child, when weather permits. I understand that school age children may apply sunscreen to themselves with supervision.This consent is in accordance with Minimum Licensing Requirements: DCCECE/ Child Care Licensing Unit: 1100.1101.17(Required)

Signature(Required)

ACKNOWLEDGMENTS

This is a statement of verification that I have been informed that child care licensing/ child maltreatment investigators and/or law enforcement may possibly interview my child for the purpose of determining licensing compliance or for investigative purposes. This is accordance with Minimum Licensing Requirements: DCCEDE/ Child Care Licensing Unit: 200.201.4

Signature(Required)

Consent(Required)

This is to acknowledge that I have received and will comply with the rules as stated in the Kids Fun FACtory Parent Handbook.

Consent(Required)

I have been informed of the behavior guidance policy practiced.

Consent(Required)

I understand that I may ask for a conference with the caregiver(s) as needed.

Signature(Required)

Discipline Policy(Required)

The discipline policy of the Fayetteville Athletic Club, Kids Fit Fun FACtory will be that any time a child's behavior jeopardizes the safety of him/herself, others or is acting in a disruptive manner, the child will be removed from the class or program. The Kids FACtory uses "timeout" to encourage good behavior. A child who has been given a "timeout" will be taken out of the group/class participation and must sit alone quietly under staff supervision for 1 minute for each year of age. After the 2nd offense, another timeout will be given. Following a 3rd offense, the child will be sent home for the remainder of the day. The parents and child will need to schedule a conference with the Director to discuss the issue. Continuous or more serious behavior issues may result in suspension/ pending termination from the Kid's Fit Fun FACtory program. I understand and agree to comply with the Discipline Policy.

Signature(Required)

CAMP PHOTOGRAPHY

We will be taking pictures throughout the year to capture the action and adventure of our Kids FACtory programs. I hereby grant permission to Fayetteville Athletic Club to use photographs and/or video of my child(ren) taken during FAC programs, in publications, news releases, online, and in other communications related to the Kid FACtory programs.

SELECT YES OR NO(Required)

Signature(Required)

FAC WAIVER RELEASE STATEMENT(Required)

I agree to the Fayetteville Athletic Club's Waiver release statement. By signing this form, I understand that I am releasing all claims for injury, I or my child may sustain through any of our programs. I agree to assume full risk and to waive, relinquish, and release all claims I and/or the participant may have against, indemnify, hold harmless and defend the Fayetteville Athletic Club. This release includes FAC officers, agents, servants, and employees from such claims resulting from injury, damages, or loss sustained while participating in the FAC program or event. I understand that I am responsible for all personal insurance and understand that I must cover any medical costs incurred for my family participating in this FAC program. I also understand that every precaution is taken to protect the safety of each participant.

Signature(Required)

JUMPSTART SUMMER CAMP PAYMENT POLICY

The Registration fee, first full week of camp fees must be paid to register for your child(ren)'s first week of summer camp. Each subsequent week my be confirmed by placing a $25 non-refundable deposit on the week(s) that your camper will attend. The balance for each week that has a deposit will be billed for the balance, the Wednesday prior to the week of camp. This balance must be paid by a credit card or bank account on file with FAC. Payments must be received for your camper to attend camp. Non-payment by the required due dates will result in relinquishing the camper's space in the program. FAC Junior Membership are required for each camper to receive the Member discount for our summer camp program. Changes or cancellation requests must be received a minimum of 2 weeks prior to the start of camp and must be made in writing to the Director. FAC member discounts will be voided and additional charges will occur if the FAC Junior membership is canceled at any time during the program duration. A $25 returned payment fee will be applied to any returned payments. Fayetteville Athletic Club accepts, Visa, Master Card, Discover, American Express, bank drafts and checks. I agree to abide by the Billing policy that has been presented.

Signature(Required)

Name as it appears on your credit card

Credit card number

Expiration date

Credit card type

VISA

Mastercard

Discover

American Express

CVV

CHOOSE YOUR WEEKS - Please remember that your registration fee, your first full week of camp and all deposits for additional weeks must be paid at the time of enrollment to reserve your spots.(Required)

REGISTRATION FEE $30

WK 1-June 3-7 4-5 YRS FULL TIME $199 Member/ $209 Guest

WK 1-June 3-7 1-3 YRS FULLTIME $199 Member/ $209 Guest

WK 1-June 3-7 1-3 YRS 3 DAYS $159 Member/ $169 Guest

WK 2- June 10-14 4-5 YRS FULL TIME $199 Member/ $209 Guest/ $25 Deposit

WK 2-June 10-14 1-3 YRS FULLTIME $199 Member/ $209/ $25 Deposit

WK 2-June 10-14 1-3 YRS 3 DAYS $159 Member/ $169 Guest/ $25 Deposit

WK 3- June 17-21 4-5 YRS FULL TIME$199 Member/ $209 Guest/ $25 deposit

WK 3- June 17-21 1-3 YRS FULL TIME$199 Member/ $209 Guest/ $25 deposit

WK 3- June 17-21, 1-3 YRS 3 DAYS $159 Member/ $169 Guest/ $25 Deposit

WK 4- June 24-28 4-5 YRS FULL TIME$199 Member/ $209 Guest/ $25 deposit

WK 4- June 24-28 1-3 YRS FULL TIME$199 Member/ $209 Guest/ $25 Deposit

WK 4- June 24-28 1-3 YRS 3 DAYS $159 Member/ $169 Guest/ $25 Deposit

WK 5- July 1,2,3& 5, 4-5 YRS FULL TIME $159 Member/ $167 Guest/ $25 Deposit

WK 5- July 1,2,3& 5, 1-3 YRS FULL TIME $159 Member/ $167 Guest/ $25 Deposit

WK 5- July 1,2,3& 5, 1-3 YRS 3 DAYS $159 Member/ $169 Guest/ $25 Deposit

WK 6- July 8-12 4-5 YRS, FULL TIME $199 Member/ $209 Guest/ $25 Deposit

WK 6- July 8-12, 1-3 YRS, FULL TIME $199 Member/ $209 Guest/ $25 Deposit

WK 6- July 8-12, 1-3 YRS, 1-3 YRS 3 DAYS $159 Member/ $169 Guest/ $25 Deposit

WK 7- July 15-19, 4-5 YRS, FULL TIME $199 Member/ $209 Guest/ $25 Deposit

WK 7- July 15-19, 1-3 YRS, FULL TIME $199 Member/ $209 Guest/ $25 Deposit

WK 7- July 15-19, 1-3 YRS 3 DAYS $159 Member/ $169 Guest/ $25 Deposit

WK 8- July 22-26, 4-5 YRS, FULL TIME $199 Member/ $209 Guest/ $25 Deposit

WK 8- July 22-26, 1-3 YRS, FULL TIME $199 Member/ $209 Guest/ $25 Deposit

WK 8- July 22-26, 1-3 YRS 3 DAYS $159 Member/ $169 Guest/ / $25 Deposit

WK 9- July 29-Aug 2, 4-5 YRS, FULL TIME $199 Member/ $209 Guest/ $25 Deposit

WK 9- July 29-Aug 2, 1-3 YRS, FULL TIME $199 Member/ $209 Guest/ $25 Deposit

WK 9- July 29-Aug 2, 1-3 YRS 3 DAYS $159 Member/ $169 Guest/ $25 Deposit

WK 10- Aug 5-8, 4-5 YRS, FULL TIME $199 Member/ $209 Guest/ $25 Deposit

WK 10- Aug 5-8, 1-3 YRS, FULL TIME $199 Member/ $209 Guest/ $25 Deposit

WK 10- Aug 5-8, 1-3 YRS 3 DAYS $159 Member/ $169 Guest/ $25 Deposit