TAC Summer Camp Enrollment 2019 If you would like to enroll for the School Year 2019-20 as well, please complete a separate form by Clicking Here: Adventure Club Enrollment CHILDCARE PAYMENT ASSISTANCE: Important Note for DSS Families: DSS will NOT pay the one-time Activity fee of $75 for each child due upon receipt of enrollment. Please make sure to leave your payment information to process this fee 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 $25 per child. All monthly co-fee's 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:*MontgomeryRadfordGilesPulaskiFloydOther - county is not listedCHILD INFORMATION:Previous Childcare Name - Type N/A if non-applicable.*How many children are you enrolling?*Rising Kindergartners to age 12 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 Child2 Children3 Children4 Children1st Child:* (M)(F) Gender First "Nickname" Last Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What grade is your 1st child RISING into?*Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade Is your child New to Adventure Club?*NewReturning1st child camp week selection:*Payment for the camp weeks you reserve will be processed each Friday prior to the week of attendance. If you need to change weeks, you MUST NOTIFY the account management team via email at: tac@the-adventureclub.com before payment is processed. If email notification is received to change weeks AFTER payment was processed, you may transfer payment to a different week, however there will be NO REFUNDS if your child is a "NO SHOW" for the reserved week. (ALL DATES LISTED BELOW ARE TENTATIVE UNTIL WE HAVE OFFICIAL DATES RELEASED FROM MCPS!) -- Dates will be updated once this is finalized. Wk 1: 6/10-6/14 Wk 2: 6/17-6/21 Wk 3: 6/24-6/28 Wk 4: 7/1-7/5 (closed 7/4) Wk 5: 7/8-7/12 Wk 6: 7/15-7/19 Wk 7: 7/22-7/26 Wk 8: 7/29-8/2 Wk 9: 8/5-8/9 Swimming Disclosure & Consent*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 in. I give 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 preservation vest while swimming. My child has not yet reached 4 ft in height and may not access any waterslides. My child is NOT ALLOWED to attend swimming field trips. 2nd Child:* (M)(F) Gender First "Nickname" Last Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What grade is your 2nd child "RISING" into?*Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade Is your child New to Adventure Club?*NewReturning2nd child camp week selection:*Payment for the camp weeks you reserve will be processed each Friday prior to the week of attendance. If you need to change weeks, you MUST NOTIFY the account management team via email at: tac@the-adventureclub.com before payment is processed. If email notification is received to change weeks AFTER payment was processed, you may transfer payment to a different week, however there will be NO REFUNDS if your child is a "NO SHOW" for the reserved week. (ALL DATES LISTED BELOW ARE TENTATIVE UNTIL WE HAVE OFFICIAL DATES RELEASED FROM MCPS!) -- Dates will be updated once this is finalized. Wk 1: 6/10-6/14 Wk 2: 6/17-6/21 Wk 3: 6/24-6/28 Wk 4: 7/1-7/5 (closed 7/4) Wk 5: 7/8-7/12 Wk 6: 7/15-7/19 Wk 7: 7/22-7/26 Wk 8: 7/29-8/2 Wk 9: 8/5-8/9 Swimming Disclosure & Consent*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 in. I give 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 preservation vest while swimming. My child has not yet reached 4 ft in height and may not access any waterslides. My child is NOT ALLOWED to attend swimming field trips. 3rd Child:* (M)(F) Gender First "Nickname" Last Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What grade is your 3rd child "RISING" into?*Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade Is your child New to Adventure Club?*NewReturning3rd child camp week selection:*Payment for the camp weeks you reserve will be processed each Friday prior to the week of attendance. If you need to change weeks, you MUST NOTIFY the account management team via email at: tac@the-adventureclub.com before payment is processed. If email notification is received to change weeks AFTER payment was processed, you may transfer payment to a different week, however there will be NO REFUNDS if your child is a "NO SHOW" for the reserved week. (ALL DATES LISTED BELOW ARE TENTATIVE UNTIL WE HAVE OFFICIAL DATES RELEASED FROM MCPS!) -- Dates will be updated once this is finalized. Wk 1: 6/10-6/14 Wk 2: 6/17-6/21 Wk 3: 6/24-6/28 Wk 4: 7/1-7/5 (closed 7/4) Wk 5: 7/8-7/12 Wk 6: 7/15-7/19 Wk 7: 7/22-7/26 Wk 8: 7/29-8/2 Wk 9: 8/5-8/9 Swimming Disclosure & Consent*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 in. I give 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 preservation vest while swimming. My child has not yet reached 4 ft in height and may not access any waterslides. My child is NOT ALLOWED to attend swimming field trips. 4th Child:* (M)(F) Gender First "Nickname" Last Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 What grade is your 4th child RISING into?*Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th GradeIs your child New to Adventure Club?*NewReturning4th child camp week selection:*Payment for the camp weeks you reserve will be processed each Friday prior to the week of attendance. If you need to change weeks, you MUST NOTIFY the account management team via email at: tac@the-adventureclub.com before payment is processed. If email notification is received to change weeks AFTER payment was processed, you may transfer payment to a different week, however there will be NO REFUNDS if your child is a "NO SHOW" for the reserved week. (ALL DATES LISTED BELOW ARE TENTATIVE UNTIL WE HAVE OFFICIAL DATES RELEASED FROM MCPS!) -- Dates will be updated once this is finalized. Wk 1: 6/10-6/14 Wk 2: 6/17-6/21 Wk 3: 6/24-6/28 Wk 4: 7/1-7/5 (closed 7/4) Wk 5: 7/8-7/12 Wk 6: 7/15-7/19 Wk 7: 7/22-7/26 Wk 8: 7/29-8/2 Wk 9: 8/5-8/9 Swimming Disclosure & Consent*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 in. I give 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 preservation vest while swimming. My child has not yet reached 4 ft in height and may not access any waterslides. My child is NOT ALLOWED to attend swimming field trips. MEDICAL INFORMATION & CONSENTS:Pediatrician's Name:*Pediatrician's Phone #:*Hospital Preference:*Carilion RadfordLewis Gale Blacksburg 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 24 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 transportNOT authorized - Please follow specific instructions in text box belowMedical 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:*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. MEDICATION CONSENT FOOD ALLERGY POA ASTHMA POAMy child(ren) have No Allergies or Special NeedsYES, 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:Parent Information:Who does the child live with?*Both Parents - SAME HomeBoth Parents - SPLIT Home1st Parent Only - Legal CustodyLegal Guardian1st Parent Relation to Child:*Biological-ParentStep-ParentFoster-ParentOther - Legal Guardian* First Last * Full Physical Address (PO Box is not a valid address): City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone #:*Name of Cell Phone Provider:*This is required so we may be able to text you as a secondary form of urgent communication. 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.EmployedUnemployedEmployer's Name:*Employer's Phone #:** Employer's Physical Address (PO Box is not a valid address): City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 2nd Parent Relation to Child:*Biological-ParentStep-ParentFoster-ParentOther - Legal GuardianDeceased/Unavailable* First Last Is the 2nd parent's physical address the same as the 1st parent?*YesNo. Please complete address information below.* Full Physical Address (PO Box is not a valid address): City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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.EmployedUnemployedEmployer's Name:*Employer's Phone #:** Employer's Physical Address (PO Box is not a valid address): City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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:*Mr.Ms.* First Last Relation to Child:*GrandmotherGrandfatherAuntUncleFamily FriendSisterBrotherSocial WorkerStep MotherStep FatherFoster MotherFoster FatherOtherCell Phone #:** Full Physical Address (PO Box is not a valid address): City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 2nd Contact:*Mr.Ms.* First Last Relation to Child:*GrandmotherGrandfatherAuntUncleFamily FriendSisterBrotherSocial WorkerStep MotherStep FatherFoster MotherFoster FatherOtherCell Phone #:** Full Physical Address (PO Box is not a valid address): City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PARENTAL AGREEMENTS & CONSENTS:Electronics & Toys:*TAC does not allow any Electronics 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'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 ChildI DO NOT Allow Photo's of My ChildField Trips:*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 tripsLate Pick-Up:*I Agree to comply with the "Late Pick-Up" policy found in the printable "Welcome Pack" found on the Summer Camp webpage.Packed Lunches & Water Bottles:**Please pack a healthy picnic lunch for your child daily. You will need to use ICE PACKS as we do NOT have the means for keeping food cold. *If you forget to pack a lunch, we will call you to remind you to bring one. *If your child has a food allergy, we will seat them at a separate table for eating as a precaution. *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.Sunscreen Application:*YES, I authorize the use of and will supply a suncreen 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:*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. I Agree to discuss the Behavioral Disclosure & review the "7 Expectations of The Adventure Club Children" found in the printable "Welcome Pack" on the Summer Camp webpage with my child(ren) and comply with its policy. 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:* First Last Today's Date:* Date Format: MM slash DD slash YYYY PAYMENT METHOD & CREDIT INFORMATIONHow would you like to pay your tuition & fees?*We accept: Visa, MC, Check Card, or Checking Account Withdrawal (ACH). (we do not accept Cash, Checks, AMEX or Discover)Credit/Check CardChecking Withdrawal (ACH)Name as it appears on the card or checking account: First Last * Billing Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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. MM DD YYYY 3 digit security code on back of card:*Name of Financial Institution:*Routing Number:*Checking Account Number:*CONFIRM Checking Account Number:*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 Friday and thereafter for the weeks I have reserved for my child. I also authorize TAC to debit my Activity fee(s) of $75 per child upon receipt of this enrollment. If my enrollment is received after 5/1/19, I also authorize TAC to debit my Registration fee(s) of $25 per child upon receipt of this enrollment. 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:* Date Format: MM slash DD slash YYYY If a confirmation screen does not appear after clicking "Submit", scroll back through your form to check for incomplete fields and Re-Submit.
