Registration Packet

Within this packet you will find everything needed to begin summer camp at Amped Up. Please let us know if you need any assistance while completing this paperwork.

INDEX Completed

Enrollment Form ……………………………………………………….… 2 Policy Agreement …………………………..………...………..….……. 3 Emergency Form ……..…………………………………………….….... 4 We also need a copy of your child's full health records. Completed copies can usually be obtained from the school nurse, your physician, or the program director at your before and after care program if enrolled. Please submit the forms below during registration.

• Health Assessment Part 1 (Parent) …………………………… 7

• Health Assessment Part 2 (Physician) ……………………….. 8

• Medication Authorization Form (If needed) …………………. 9

• Immunization Record

Amped Up! Family Amphitheatre, LLC info@2ampedup.com 11600 Crossroads Circle, Suites J-M www.2ampedup.com Middle River, MD 21220 www.facebook.com/AmpedUpTheatre 877-2-AMPED-UP (877-226-7338) 410-335-1305

ENROLLMENT FORM

A.M.P. Camp 2020 Please select the weeks for which you are registering: June 22-26 July 13-17 Aug. 3-7 Aug. 24-28 June 29-July 3 July 20-24 Aug. 10-14 Aug. 31-Sept. 4 July 6-10 July 27-31 Aug. 17-21

Please select your needs regarding before or after camp care:

No Extended Care Before Care Only After Care Only Before & After Care

Child’s Name: ____________________________________________________________________

Last First Middle

Address: ___________________________________________________________________________ Street City Zip Code

Birth Date: _______________ Sex: ____ Age: ____ Shirt Size: Youth – XS, S, M, L, XL Adult – S, M, L Month/Day/Year Circle One

School: _____________________________________________________ Grade (Next year): _______

Parent/Guardian #1: ____________________________________________________________

Last First Middle

Address: __________________________________________________________________________ Street City Zip Code

Phone # 1: __________________________ Phone # 2: __________________________

Email: ________________________________ Authorized to Pickup: Yes No

Parent/Guardian #2: ____________________________________________________________

Last First Middle

Address: __________________________________________________________________________ Street City Zip Code

Phone # 1: __________________________ Phone # 2: __________________________

Email: ________________________________ Authorized to Pickup: Yes No

Please list any concerns regarding your child (Medical, behavioral, emotional, IEP/504 Plan):

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

2 Summer Camp Registration Packet– Amped Up! www.2ampedup.com

(Office Use Only) Camp Weeks: ___________________ Notes: _________________________

Policy Agreement

A.M.P. Camp 2020 _______________________________ ___________________________________________ Parent/Guardian Name Name of Child(ren)

Program Interaction, Supervision, and Guidelines

1. I understand that I am not to leave my child at Amped Up unless a staff member is present to receive and supervise them.

2. I understand that my child will not be allowed to leave the program with any unauthorized person. Any person authorized to pick up my child must be listed on the enrollment form or emergency form.

3. Should I, or any authorized person, arrive to pick up my child with the appearance of being under the influence of alcohol or drugs, I am aware that Amped Up staff may contact the proper authorities.

4. I understand that Amped Up is mandated by Maryland law to report any suspected child abuse or neglect to the appropriate authorities for investigation.

5. Participation in the program may be terminated for verbal abuse, physical altercations, or any other behaviors deemed unacceptable.

6. Amped Up staff members are not permitted to provide child care or transportation outside of the program.

7. I understand that my child’s photograph may be used in promotional materials. Unidentifiable group shots will be used in most circumstances and permission will be sought for individual or discernable photos.

8. Outside items (Such as video games, books, etc.) may be brought to camp. While we do provide storage for each camper, Amped Up is not responsible for loss of or damage to these items or other personal belongings.

9. All medications (Including topical lotions) must be self administered by each child. Camp staff may supervise, but cannot apply or administer medication. Any medication not picked up by the end of camp will be disposed.

10. Children may not attend camp if they are sick, especially with symptoms such as vomiting, diarrhea, fever, rash, or other contagious conditions. Campers should be symptom free for 24 hours before returning and may need a doctor’s note if diagnosed with any of the above conditions.

Financial Responsibilities & Terms

1. A $100 deposit per child is due upon enrollment in summer camp.

2. Camp tuition is due one week prior to the beginning of each session. A $20 fee will apply to all late payments.

3. Deposits are non-refundable. Any remaining camp tuition can be refunded up until two weeks prior to the beginning of each camp week.

4. Full camp tuition is due regardless of scheduled days off, sick days, or other occurrences. You are responsible for payment for all selected weeks on the enrollment form.

5. An afternoon snack will be provided by the camp, but lunch and all other meals are the responsibility of each parent/guardian. Our concession area will be open for snack purchases, but lunch CANNOT be ordered.

I agree to the above terms for summer camp at Amped Up.

__________________________________________________________________

Signature Date 3 Summer Camp Registration Packet– Amped Up! www.2ampedup.com

(Office Use Only) Camp Weeks: ___________________ Notes: _________________________

EMERGENCY FORM INSTRUCTIONS TO PARENTS: (1) Complete all items on this side of the form. Sign and date where indicated. (2) If your child has a medical condition which might require emergency medical care, complete the back side of the form. If necessary, have your child’s

health practitioner review that information. NOTE: THIS ENTIRE FORM MUST BE UPDATED ANNUALLY. When parents cannot be reached, list at least one person who may be contacted to pick up the child in an emergency: 1. Name _____________________________________________________________ Telephone (H) _________________ (W) __________________

Last First Address _________________________________________________________________________________________________________________ Street/Apt.# City State Zip Code 2. Name ______________________________________________________________ Telephone (H) _________________ (W) __________________ Last First Address _________________________________________________________________________________________________________________ Street/Apt.# City State Zip Code 3. Name ______________________________________________________________ Telephone (H) _________________ (W) __________________ Last First Address _________________________________________________________________________________________________________________ Street/Apt.# City State Zip Code Child’s Physician or Source of Health Care ___________________________________________________ Telephone ____________________________ Address _____________________________________________________________________________________________________________________ Street/Apt.# City State Zip Code In EMERGENCIES requiring immediate medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. Your signature authorizes the responsible person at the child care facility to have your child transported to that hospital. Signature of Parent/Guardian _________________________________________________________ ___Date ___________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Child’s Name ___________________________________________________________________________ Birth Date ___________________________ Last First Enrollment Date ______________________________ Hours & Days of Expected Attendance ____________________________________ Child’s Home Address __________________________________________________________________________________________________________ Street/Apt.# City State Zip Code Mother’s Name _________________________________________________________________ Home Telephone _____________________________ Last First Mother’s Employer/School _______________________________________________________________________________________________________ Name Address Mother’s Home Address (If different from above) _____________________________________________________________________________________ Street/Apt.# City State Zip Code Work Telephone _________________________________ Cellular Phone ___________________________ Beeper _____________________________ Father’s Name _________________________________________________________________ Home Telephone _____________________________ Last First Father’s Employer/School _______________________________________________________________________________________________________ Name Address Father’s Home Address (If different from above) ______________________________________________________________________________________ Street/Apt.# City State Zip Code Work Telephone ______________________________ Cellular Phone __________________________ Beeper _____________________________ Name of Person Authorized to Pick Up Child (daily) ___________________________________________________________________________________ Last First Relationship to Child Address _____________________________________________________________________________________________________________________ Street/Apt.# City State Zip Code ANNUAL UPDATES _____________________ ______________________ ______________________ ______________________ (Initials/Date) (Initials/Date) (Initials/Date) (Initials/Date) OCC 1214 (Revised 7/05) - Side 1 of 2 - All previous editions are obsolete.

INSTRUCTIONS TO PARENT: (1) Complete the following items, as appropriate, if your child has a condition(s) which might require emergency medical

care. (2) If necessary, have your child’s health practitioner review the information you provide below and sign and date where

indicated. Child’s Name: ___________________________________________________ Date of Birth: _______________________ Medical Condition(s): _________________________________________________________________________________ ____________________________________________________________________________________________________________________________ Medications currently being taken by your child: ____________________________________________________________ ____________________________________________________________________________________________________________________________ Date of your child’s last tetanus shot: _____________________________________________________________________ Allergies/Reactions: ___________________________________________________________________________________ ____________________________________________________________________________________________________________________________ EMERGENCY MEDICAL INSTRUCTIONS: (1) Signs/symptoms to look for: _________________________________________________________________________ ____________________________________________________________________________________________________________________________ (2) If signs/symptoms appear, do this: _____________________________________________________________________ (3) To prevent incidents: _______________________________________________________________________________ ____________________________________________________________________________________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ OTHER SPECIAL MEDICAL PROCEDURES THAT MAY BE NEEDED: __________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ COMMENTS: ________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________

Note to Health Practitioner: If you have reviewed the above information, please complete the following: ________________________________________________ ____________________________________ Name of Health Practitioner Date _________________________________________________ (_____)______________________________ Signature of Health Practitioner Telephone Number OCC 1214 (Revised 7/05) - Side 2 of 2 - All previous editions are obsolete.

MARYLAND STATE DEPARTMENT OF EDUCATION

Office of Child Care

HEALTH INVENTORY Information and Instructions for Parents/Guardians REQUIRED INFORMATION The following information is required prior to a child attending a Maryland State Department of Education licensed, registered or approved child care or nursery school:

• A physical examination by a physician or certified nurse practitioner completed no more than twelve months prior to attending child care. A Physical Examination form designated by the Maryland State Department of Education and the Department of Health and Mental Hygiene shall be used to meet this requirement (See COMAR 13A.15.03.02, 13A.16.03.02 and 13A.17.03.02).

• Evidence of immunizations. A Maryland Immunization Certification form for newly enrolling children may be obtained from the local health department or from school personnel. The immunization certification form (DHMH 896) or a printed or a computer generated immunization record form and the required immunizations must be completed before a child may attend. This form can be found at:

http://ideha.dhmh.maryland.gov/IMMUN/pdf/896_form.pdf

• Evidence of Blood-Lead Testing for children living in designated at risk areas. The blood-lead testing certificate (DHMH 4620) (or another written document signed by a Health Care Practitioner) shall be used to meet this requirement. This form can be found at:

http://apps.fcps.org/dept/health/MarylandDHMHBloodLeadTestingCertificateDHMH4620.pdf EXEMPTIONS Exemptions from a physical examination, immunizations and Blood-Lead testing are permitted if the family has an objection based on their religious beliefs and practices. The Blood-Lead certificate must be signed by a Health Care Practitioner stating a questionnaire was done. Children may also be exempted from immunization requirements if a physician, nurse practitioner or health department official certifies that there is a medical reason for the child not to receive a vaccine.

The health information on this form will be available only to those health and child care provider or child care personnel who have a legitimate care responsibility for your child.

INSTRUCTIONS Please complete Part I of this Physical Examination form. Part II must be completed by a physician or nurse practitioner, or a copy of your child's physical examination must be attached to this form. If your child requires medication to be administered during child care hours, you must have the physician complete a Medication Authorization Form (OCC 1216) for each medication. The Medication Authorization Form can be obtained at http://www.marylandpublicschools.org/NR/rdonlyres/B0050A99-6B3C-4396-A996-CC9405971A42/30754/1216_MedAuth_r120511.pdf If you do not have access to a physician or nurse practitioner or if your child requires an individualized health care plan, contact your local Health Department. OCC 1215 - Revised 12/11 - All previous editions are obsolete and replaces OCC 1215A, and OCC 8506. Page 1 of 4

PART I - HEALTH ASSESSMENT To be completed by parent or guardian

Child’s Name: Birth date: Sex Last First Middle Mo / Day / Yr M F

Address:

Number Street Apt# City State Zip Parent/Guardian Name(s) Relationship Phone Number(s)

W: C: H: W: C: H:

Where do you usually take your child for routine medical care? Name:

Address: Phone Number:

When was the last time your child had a physical exam? Month: Year:

Where do you usually take your child for dental care? Name:

Address: Phone Number: ASSESSMENT OF CHILD’S HEALTH - To the best of your knowledge has your child had any problem with the following? Check Yes or No and provide a comment for any YES answer. Yes No Comments (required for any Yes answer) Allergies (Food, Insects, Drugs, Latex, etc.)

Allergies (Seasonal)

Asthma or Breathing

Behavioral or Emotional

Birth Defect(s)

Bladder

Bleeding

Bowels

Cerebral Palsy

Coughing

Developmental Delay

Diabetes

Ears or Deafness

Eyes or Vision

Head Injury

Heart

Hospitalization (When, Where)

Lead Poisoning/Exposure

Life Threatening Allergic Reactions

Limits on Physical Activity

Meningitis

Prematurity

Seizures

Sickle Cell Disease

Speech/Language

Surgery

Other

Does your child take medication (prescription or non-prescription) at any time?

No Yes, name(s) of medication(s):

Does your child receive any special treatments? (nebulizer, epi-pen, etc.)

No Yes, type of treatment:

Does your child require any special procedures? (catheterization, G-Tube, etc.)

No Yes, what procedure(s):

I GIVE MY PERMISSION FOR THE HEALTH PRACTITIONER TO COMPLETE PART II OF THIS FORM. I UNDERSTAND IT IS FOR CONFIDENTIAL USE IN MEETING MY CHILD’S HEALTH NEEDS IN CHILD CARE.

I ATTEST THAT INFORMATION PROVIDED ON THIS FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF. Signature of Parent/Guardian Date

OCC 1215 - Revised 12/11 - All previous editions are obsolete. Page 2 of 4

PART II - CHILD HEALTH ASSESSMENT To be completed ONLY by Physician/Nurse Practitioner

Child’s Name: Birth Date: Sex Last First Middle Month / Day / Year M F

1. Does the child named above have a diagnosed medical condition?

No Yes, describe: 2. Does the child have a health condition which may require EMERGENCY ACTION while he/she is in child care? (e.g., seizure, allergy, asthma,

bleeding problem, diabetes, heart problem, or other problem) If yes, please DESCRIBE and describe emergency action(s) on the emergency card.

No Yes, describe: 3. PE Findings

Health Area WNL ABNL Not

Evaluated Health Area WNL ABNL Not

Evaluated Attention Deficit/Hyperactivity Lead Exposure/Elevated Lead Behavior/Adjustment Mobility Bowel/Bladder Musculoskeletal/orthopedic Cardiac/murmur Neurological Dental Nutrition Development Physical Illness/Impairment Endocrine Psychosocial ENT Respiratory GI Skin GU Speech/Language Hearing Vision Immunodeficiency Other: REMARKS: (Please explain any abnormal findings.) 4. RECORD OF IMMUNIZATIONS – DHMH 896/or other official immunization document (e.g. military immunization record of immunizations) is

required to be completed by a health care provider or a computer generated immunization record must be provided. (This form may be obtained from: http://ideha.dhmh.maryland.gov/IMMUN/pdf/896_form.pdf)

RELIGIOUS OBJECTION:

I am the parent/guardian of the child identified above. Because of my bona fide religious beliefs and practices, I object to any immunizations being given to my child. This exemption does not apply during an emergency or epidemic of disease.

Parent/Guardian Signature: Date: 5. Is the child on medication?

No Yes, indicate medication and diagnosis: (OCC 1216 Medication Authorization Form must be completed to administer medication in child care). 6. Should there be any restriction of physical activity in child care?

No Yes, specify nature and duration of restriction:

7. Test/Measurement Results Date Taken Tuberculin Test Blood Pressure Height Weight BMI %tile Lead Test Indicated: Yes No

(Child’s Name) has had a complete physical examination and any concerns have been noted above.

Additional Comments:

Physician/Nurse Practitioner (Type or Print):

Phone Number:

Physician/Nurse Practitioner Signature:

Date:

OCC 1215 - Revised 12/11 - All previous editions are obsolete. Page 3 of 4

MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care

MEDICATION AUTHORIZATION FORM

Regulations permit child care providers to give prescription and non-prescription medication to children in care under certain conditions with prior written permission (Section A) from the child’s parent. A separate form is needed for each prescription or non-prescription medication to be administered to the child. PRESCRIPTION MEDICATIONS AND NON-PRESCRIPTION MEDICATIONS: Prescription medications must be in a container labeled by the pharmacy or physician with the child’s name, dosage, and expiration date. At least one dose of prescription medication must be given at home prior to the child’s arrival at the child care facility. Non-prescription medications must be in the original manufacturer’s container labeled with instructions for dosage and expiration date. Except for OCC approved topical medications, a provider may administer only one dose of nonprescription medication to a child per illness unless a licensed health practitioner provides written approval (Section B) of the administration of the nonprescription medication and the dosage. All medication shall be administered according to the instructions on the label of the medication container. If Section B is not signed by the health practitioner, the health practitioner may give oral permission and instructions to the parent directly. If oral permission and instruction is given, the parent must complete Sections B and C below. Name of Child: Date of Birth: SECTION A:

MEDICATION DOSAGE WHEN TO GIVE DATES TO ADMINISTER Start: Stop: This medication is being given for the following condition(s): ADDITIONAL INSTRUCTIONS (including instructions not given on the prescription): Note any side effects of this medication: Note any reasons or conditions when this medication should be stopped or not given: I authorize to administer the above named medication to my child. Name of Child Care Provider or Facility: Signature of Parent/Guardian: _________________________________________ Date: ___________________

SECTION B:

PHYSICIAN’S APPROVAL IF MORE THAN ONE DOSE OF NON-PRESCRIPTION MEDICATION IS TO BE GIVEN

(OTHER THAN OCC APPROVED TOPICAL MEDICATIONS) Instructions for more than one dose of a non-prescription medication: Note any side effects of this medication:

Note any reasons or conditions when this medication should be stopped or not given:

Signature of Health Practitioner: Date: Stamp, Print or Type Name of Health Practitioner: Phone #:

SECTION C:

If Section B is not signed by the health practitioner, the health practitioner may give oral permission and instructions to the parent directly. If oral permission and instruction is given, the parent must complete Section B and the following: Name of Practitioner Giving Oral Advice to Parent: Date:

OCC 1216 - Revised 12/11 - All previous editions are obsolete. Page 1 of 2