Summer Camp Enrollment Form | The Adventure Club

Adventure Valley Summer Camp 2024

"*" indicates required fields

Fun Summer Care for boys & girls ages 5-10 years old.

Childcare Payment Assistance:

Important Note for DSS Families:
DSS will NOT pay the one-time Activity fee of $50 for each child due upon receipt of enrollment. There is also a $30 difference due weekly for tuition costs that DSS does not cover. Please make sure to leave your payment information to process your child's acitivity fee & weekly difference for tuition when asked on this enrollment form! DSS may or may not pay each child's registration fee. If they do not pay, the parent is responsible for paying the $50 per child. All monthly co-fee's (if any) are outlined by social services, speak with your worker to determine if you will or will not have one.

Please choose one of the following:*

I DO NOT receive state subsidy (DSS) assistance or foster a child.

I am currently approved and receiving subsidy childcare assistance.

I have applied for subsidy assistance and I am currently on the wait list. STOP! You will be responsible for ALL fees and tuition until approved.

My child is part of the foster care system.

Which county are you receiving assistance from:*

Montgomery

Radford

Giles

Pulaski

Floyd

Other - county is not listed

Child Information:

Is your child/ren New to Adventure Club?*

New

Returning - ALL information TAC has is up to date

Returning - I need to update my information

How many children are you enrolling?*
Ages 5 - 10 years old qualify. If your child is a rising Pre-Kindergartner, Christiansburg GraceAChild (540-382-9591) and Radford GraceAChild (540-831-7222) offer care for this age group.

1 Child

2 Children

3 Children

4 Children

REQUIRED DOCUMENTS -- NEW FAMILIES ONLY!

UPLOAD:

1. Proof of birth (BIRTH CERTIFICATE), recent immunizations, and last physical/well visit. Your child CANNOT START UNTIL RECEIVED!

2. Parents are required to obtain these documents. ADVENTURE CLUB DOES NOT REQUEST DOCUMENTS FROM THE SCHOOLS! Click this link to complete needed forms if you have not done so already for the school:
School Entrance Health Form (PDF)

-- THESE MUST BE COMPLETED BY YOUR CHILD'S PHYSICIAN.

4. YOU MAY UPLOAD THEM BELOW OR FAX to 540-382-6529 or SCAN & EMAIL to: [email protected]

Max. file size: 100 MB.

1st Child:*

1st Child:

Gender First "Nickname" Last

Date of Birth:*

What grade is your 1st child RISING into?*

1st Child Swimming Disclosure & Consent*

I give my permission for my child to go on swimming trips with The Adventure Club.

My child's swimming skill level REQUIRES them to wear a USCG approved life vest while swimming

My child is NOT ALLOWED to swim on swimming field trips.

We will let you know ahead of time when your child will need to wear their swimsuit. On swim days, you will need to supply them with a change of clothes & a towel inside of a plastic grocery bag so that wet clothes can go back in it to return home.

Children who are not swimming on swim field trips will not be left at Summer Camp they just won't be swimming. If you do not wish your child to be at the swim location on swim days, please keep them at home.

2nd Child:*

2nd Child:

Gender First "Nickname" Last

Date of Birth:*

What grade is your 2nd child "RISING" into?*

2nd Child Swimming Disclosure & Consent*

I give my permission for my child to go on swimming trips with The Adventure Club.

My child's swimming skill level REQUIRES them to wear a USCG approved life vest while swimming

My child is NOT ALLOWED to swim on swimming field trips.

3rd Child:*

3rd Child:

Gender First "Nickname" Last

Date of Birth:*

What grade is your 3rd child "RISING" into?*

3rd Child Swimming Disclosure & Consent*

I give my permission for my child to go on swimming trips with The Adventure Club.

My child's swimming skill level REQUIRES them to wear a USCG approved life vest while swimming

My child is NOT ALLOWED to swim on swimming field trips.

4th Child:*

4th Child:

Gender First "Nickname" Last

Date of Birth:*

What grade is your 4th child RISING into?*

4th Child Swimming Disclosure & Consent*

I give my permission for my child to go on swimming trips with The Adventure Club.

My child's swimming skill level REQUIRES them to wear a USCG approved life vest while swimming

My child is NOT ALLOWED to swim on swimming field trips.

Medical Information & Consents:

*I have chosen to use my current Medical Information & Consents listed in my file at The Adventure Club*

Pediatrician's Name:*

Pediatrician's Phone #:*

Hospital Preference:*

Child Illness & Communicable Disease:*

If you're notified that your child is ill, you agree to arrange for yourself or one of your listed contacts to pick your child up within 1 hr. If your child or a member of your immediate household become ill or exposed to a Communicable Disease, you agree to notify TAC within 48 hrs.

I Agree to Comply with TAC's Child Illness Policy

Child Illness & Injuries:*

I Agree to comply with the "Child Illness & Injuries" policy found in the printable "Welcome Pack" on the Summer Camp webpage.

Emergency Medical Release & Hospital Transport:*

In the event I cannot be reached, I authorize TAC to act on my behalf for my child to receive emergency care, and if deemed necessary, arrange for emergency transport to the hospital of my choice.

I authorize TAC to provide care or arrange hospital transport

NOT authorized - Please follow specific instructions in text box below

Specific Instructions:

Medical Care After Program Attendance:*

In the event your child sustains an injury while in our care but is NOT transported to the hospital or doctor from our site location, you agree to contact the main office at 540-382-3783 within 24 hrs, should you decide at a later time to take your child to the hospital or doctor to be evaluated. Per Virginia State Licensing Standards, The Adventure Club is mandated to report any medical treatment sought for the child's injury AFTER the child has been picked up from our program.

I agree to contact TAC's main office within 24 hrs of my child's injury should I seek medical attention after picking them up from the program.

Allergies & Special Needs:*

Allergies & Special Needs:

If your child requires any medication, we MUST have a signed medication consent and the medicine supplied in the original box with your child's full name, DOB, and name of medication on the box. We will NOT ACCEPT any medication that DOES NOT meet these requirements! On the med consent form we require both sections to be completed if the medication is by prescription only (not over the counter). The parent completes section 1 and the physician completes section 2. If you're supplying an Epi Pen or Inhaler the physician MUST also complete the appropriate plan of action.If medication needs to be administered, please click the link below to the Medicine Consent Form and have the pediatrician complete it. With the completed form, provide your child’s medicine in its original box to the director of the center. Describe any specific details in the box below.

Medication Consent (PDF)
VA Athsma Action Plan (PDF)
General Healthcare Plan (PDF)
Food Allergy & Anaphylaxis Emergency Care Plan (PDF)

My child(ren) have NO Allergies or Special Needs

YES, my child(ren) have conditions for you to be aware of - Please describe condition and for which child in the text box below. I Agree to comply with the "Administration of Medication" policy located in the printable "Welcome Pack" found on the Summer Camp webpage.

Specific Instructions:

REQUIRED DOCUMENTS! -- Must either upload here, Scan & email it to [email protected], OR fax it to us at 540-382-6529

UPLOAD MEDICAL DOCUMENTS HERE:

Max. file size: 100 MB.

Parent Information:

1st Parent:

Who does the child live with?*

1st Parent Relation to Child:*

*

Prefix First Last

*I have chosen to use my current address & employment Information listed in my file at The Adventure Club*

*
Full Physical Address (PO Box is not a valid address): City State ZIP Code

Cell Phone #:*

Email Address Required for Primary Parent/Payer:*
Please check your email regularly for important notices & account statements.

1st Parent Employment Status:*
Va state licensing requires that we obtain your current employers address and phone # if employed.

Employed

Unemployed

Employer's Name:*

Employer's Phone #:*

*
Employer's Physical Address (PO Box is not a valid address): City State ZIP Code

2nd Parent:

2nd Parent Relation to Child:*

*
Prefix First Last

Is the 2nd parent's physical address the same as the 1st parent?*

Yes

No. Please complete address information below.

*I have chosen to use my current address & employment Information listed in my file at The Adventure Club*

*
Full Physical Address (PO Box is not a valid address): City State ZIP Code

Cell Phone #:*

EMAIL ADDRESS ~ Email address is optional for second parent.

2nd Parent Employment Status:*
Va state licensing requires that we obtain your current employers address and phone # if employed.

Employed

Unemployed

Employer's Name:*

Employer's Phone #:*

*
Employer's Physical Address (PO Box is not a valid address): City State ZIP Code

Authorized Emergency Contacts:

MUST Provide 2 Emergency Contacts that live within 1 hr of child's location. CANNOT BE PARENT/GUARDIANS!

1st Contact:*
1st Contact:

Prefix First Last

Relation to Child:*

Cell Phone #:*

*

Full Physical Address (PO Box is not a valid address): City State ZIP Code

2nd Contact:*
2nd Contact:
Prefix First Last

Relation to Child:*

Cell Phone #:*

*

Full Physical Address (PO Box is not a valid address): City State ZIP Code

Parental Agreements & Consents:

Electronics & Toys:*
Electronics & Toys:
TAC does NOT allow any Electronics (including cell phones) or Toys to be brought to camp. If a child is found with one of these items, it will be put away and given back at the end of the day.
I Agree to comply with TAC's "No Electronics or Toys" policy

Photo Consent:*
Photo's:
Photos are reviewed prior to posting on Facebook to ensure proper exposure. TAC WILL NEVER publicly post children's names without parental consent!

I Agree to Allow Photos of My Child

I DO NOT Allow Photo's of My Child

Field Trips:*
Field Trips:
Adventure Valley Summer Camp tuition includes ALL field trip fees for all children. If you Opt-Out your child from attending any field trips, there will be no discounts to waive this option.

I Agree to allow my child to attend field trips. I will also agree to review the transportation rules with my child located in the printable "Welcome Pack" on the Summer Camp page of the website.

I Opt-Out of my child attending any field trips

Late Pick-Up Policy: (Summer Camp Hours are: 7 AM - 5:30 PM)*
Late Pick-Up Policy: (Summer Camp Hours are: 7 AM - 5:30 PM)
• Clock out time from 5:31 pm to 5:35 pm incurs an automatic $10.00 fee. From 5:36 pm and after, an additional $1 per minute will be charged until the child is clocked out of TAC's site computer. • The next business day, the accounts manager will process applicable fees to the parents account ledger and notify the parent by email with a statement of charges attached. • If the account is set up for autopay, the fee will be processed automatically! Otherwise, payment will be due with your next scheduled tuition payment. • If late pick-up occurs more than 3 times, a 3-day suspension will be implemented immediately following the 3rd late pick-up. If late pick-up continues, childcare services may be terminated.

I Agree to comply with the "Late Pick-Up" policy.

Water Bottles:*
Water Bottles:
*Please bring a water bottle with your child's name written on it with a sharpie pen to use throughout the day.*

I Agree to the above requirements.

Pack Iced Lunch Daily:*
Pack Lunch Daily:
*Please pack a peanut free iced lunch for your child daily. We will not be providing lunch however we will be providing breakfast & snack.*

I Agree to the above requirements.

Sunscreen Application:*
Sunscreen Application:

YES, I authorize the use of and will supply a sunscreen SPF 30+ for TAC staff to apply to my child. (Children 9+ may apply themselves. Please write your child's full name and date of birth on the bottle)

NO, I do NOT authorize use of sunscreen. (If no, please list any adverse effects below).

Adverse effects of sunscreen use:*

Behavioral Disclosure:*
Behavioral Disclosure:
Please take some time to speak with your child about wrong and right behaviors that will help them understand that summer camp is a privilege to attend. Children who run away, consistently not listen / defiant, or lay hands on another child are unacceptable behaviors during ALL camp activities and which could further forfeit their privilege to attend field trips. NO REFUNDS or discounts will be issued if the child cannot attend field trips.
Please review these expectations with your child often! If we are all on the same page, we can work together to solve problems before they start.
I Agree to discuss the Behavioral Disclosure & review the "7 Expectations of The Adventure Club Children" found on the Summer Camp "Welcome Packet" listed on the website with my child(ren) and comply with its policy.

Parent Handbook:*
Parent Handbook:
TAC reserves the right to make changes in the parent handbook to maintain compliance & integrity of the program. Click Here to view:
I Agree to review TAC's Parent Handbook

Parent Electronic Signature for Enrollment:*
Parent Electronic Signature for Enrollment:
First Last

Today's Date:*
MM slash DD slash YYYY

Payment Method:

No Pause Tuition:*
No Pause Tuition:
Payment for camp will be processed each Thursday prior to the week of service. Tuition is $195 per week for 10 weeks with no pause (closed the week of July 1st - 5th NOT billed this week) Should you decide to withdraw from the program, we require a 1-week written notice of withdrawal using the Seer parent portal (FASTEST RESPONSE TIME) or you may email your withdrawal request to: [email protected]. NO REFUNDS will be issued if your child is a "NO SHOW".

I understand and agree that I have read this information

How would you like to pay your tuition & fees?*
How would you like to pay your tuition & fees?
We accept: ALL major credit cards. Credit card processing fees will be added on to tuition - Our software does this automatically (processing fee of 3.4% + $0.50 cents per transaction), or Checking Account Withdrawal (ACH BANK DRAFT - MUST BE DONE BY PARENT WITHIN PARENT PORTAL) (processing fee of 0.95 % + $0.25 cents per transaction.) -- ( Personal Checks are accepted with no additional fee -- during the Summer, checks may be give to your child's Site Manager each Thursday PRIOR to your child's attendance the following week )

Credit/Check Card

Personal Check -- TURNED INTO YOUR CHILD'S SITE MANAGER OR THE MAIN OFFICE THE WEEK BEFORE TUITION IS DUE!

ACH Bank Draft -- I understand I will have to set this up myself inside the Childcare Seer Parent Portal once it is made available to me.

Please use payment information you have on file.

Name as it appears on the card or checking account:
First Last

*
Billing Address City State ZIP Code

Phone #:*

Email Address:*

Credit/Check Card #:*

CONFIRM Credit/Check Card #:*

Expire Date:*
If your card only shows the MM/YYYY, you may just enter the last date of the month in the "DD" space.
Month
Day
Year

3 digit security code on back of card:*

Payment Agreement & Authorization*
By typing my name below, I acknowledge that I am responsible for all tuition & fees that I incur upon receipt of this enrollment and while my child is actively enrolled in Summer Camp at TAC.

I authorize TAC to debit Summer camp tuition on a weekly basis each Thursday and understand tuition is not based on my attendance and does not stop while enrolled.

I also authorize TAC to debit my Activity fee(s) of $50 per child as well as my Registration Fee(s) of $50 per child upon receipt of this enrollment.

I understand that ALL enrollment fees are Non-Refundable!
I agree to the terms of payment and authorize TAC to debit my account as applicable.

Electronic Signature for Payment Agreement:*
First Last

Today's Date:*
MM slash DD slash YYYY

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