Escape to Adventure & Counselor Cadet Sign Ups

ThorntonParksLogo

Registration Info

Youth Info

Youths Name

Home Phone Number

Date of Birth

Gender

Male Female

Hair Color

Eye Color

Home Address

Address Line

Address Line 2

City

State

Zip

Guardian Info

Guardians Name

Address (if different than youth's)

Address Line

Address Line 2

City

State

Zip

Place of Employment

Guardians Email

Work Phone Number

Place of Employment Address

Address Line

Address Line 2

City

State

Zip

Guardian Info

Guardians Name

Address (if different than youth's)

Address Line

Address Line 2

City

State

Zip

Place of Employment

Guardians Email

Work Phone Number

Place of Employment Address

Address Line

Address Line 2

City

State

Zip

Person's Authororized to Pick Up Youth

(Please include self)

Pick-Up Person Info

Pick-Up Person Name

Pick-Up Person Phone Number

Pick-Up Person Work/Alternate Phone Number

Relationship to Participant

Pick-Up Person Address

Address Line

Address Line 2

City

State

Zip

Pick-Up Person Info

Pick-Up Person Name

Pick-Up Person Phone Number

Pick-Up Person Work/Alternate Phone Number

Relationship to Participant

Pick-Up Person Address

Address Line

Address Line 2

City

State

Zip

Pick-Up Person Info

Pick-Up Person Name

Pick-Up Person Phone Number

Pick-Up Person Work/Alternate Phone Number

Relationship to Participant

Pick-Up Person Address

Address Line

Address Line 2

City

State

Zip

Emergency Contacts to call if guardian cannot be reached and medical authorization may be obtained

Emergency Contact Info

Emergency Contact Name

Emergency Contact Cell Phone Number

Emergency Contact Relationship

Emergency Contact Work Phone Number

Emergency Contact Address

Address Line

Address Line 2

City

State

Zip

Emergency Contact Info

Emergency Contact Name

Emergency Contact Cell Phone Number

Emergency Contact Relationship

Emergency Contact Work Phone Number

Emergency Contact Address

Address Line

Address Line 2

City

State

Zip

Emergency Contact Info

Emergency Contact Name

Emergency Contact Cell Phone Number

Emergency Contact Relationship

Emergency Contact Work Phone Number

Emergency Contact Address

Address Line

Address Line 2

City

State

Zip

Medical Information

Doctor Info

Doctors Name

Doctors Phone Number

Doctors Address

Address Line

Address Line 2

City

State

Zip

Dentist Info

Dentists Name

Dentists Phone Number

Dentists Address

Address Line

Address Line 2

City

State

Zip

Youths Insurance Provider

Group Number

ID Number

Hospital Preference

Preferred Hospital Address

Address Line

Address Line 2

City

State

Zip

Any Allergies or Health Problems We Need To Be Aware Of

Special Instructions

Emergency Medical Authorization

I, , hereby give permission to the City of Thornton Staff to call a doctor for medical or surgical care for my youth, , should an emergency situation arise. It is understood that a conscious effort will be made to locate my spouse or me before any action will be taken, but if it is not possible to locate us, this expense will be expected by us.

I understand that it is my responsibilty to apply sunscreen to my youth before bring him/her to camp.

Guardians Signature

Date Signed

Family Questionnaire In order for us to best help meet youth’s needs, please answer the following questions. Our goal is to meet the needs of all the campers

Participant's Name

Participant's Nickname

What are the youth’s interests and/or what does the youth enjoy doing?
Does the youth have any issues participating in large group activities?
Yes No

If yes, please explain:
Are there any activities or foods the youth is unable to participate in due to medical, physical, social or religious reasons? Please Explain:
How does the youth express anger or react to frustration? What strategy works best to help calm the youth? i.e. taking a break, asking for help, counting to 10, change location, etc.
What strategies are used at home or school to address disruptive behavior?
What items or activities are used to help motivate the youth if they are struggling with structure?
When the youth refuses to follow instruction, how do you address this? What items, phrases, or activities are used to reward the youth when they follow instruction?
Is there any other information we should know to best work with the youth (therapy youth has, special needs, temperament, what you would like to see take place in camp, etc.)?

Participant Permissions Sheet

Participants Name

PG MOVIES

I give my permission for my youth to watch PG movies during camp. All of the movies are screened BEFORE they are shown at camp. Signature

PG-13 MOVIES

I give my permission for my youth to watch PG-13 movies during camp. All of the movies are screened BEFORE they are shown at camp. Signature

NATURE WALKS AND WALKING FIELD TRIPS

I allow my youth to participate in supervised nature walks and walking field trips within one mile area surrounding the Thornton Community Center. Signature

FIELD TRIPS AND PARTICIPATION

I give permission for the youth to go on field trips and participate in program activities on site and away from the Thornton Community Center, whether on foot or by school or RTD bus. Signature

Please list any field trip exceptions here:

MEDIA RELEASE

I hereby grant the City of Thornton Recreation Department permission to utilize photos for media and promotion for use with Thornton Recreation Programs. Signature

ARTS & CRAFTS

I allow my youth to participate in various arts and crafts during camp. I understand they will be using various tools and equipment including but not limited to scissors, glue, plaster, paint, small beads and markers. Signature

CELL PHONE USE

I would like my youth to bring their cell phone to camp. We have discussed the policy and agree that, if staff feels that cell phone use interferes with camp activities, the phone will be confiscated and I will pick it up when I pick my youth up from camp. Signature

Guardian & Participant Contract

We have read and understand the policies and procedures outlined in the parent information packet.

Legal Guardian's Initials

Participant's initials
We will abide by the rules set by the camp staff in order to ensure the safety and well-being of all participants and their families

Legal Guardian Initials

Participant's Initials
We understand the process followed should disciplinary measures be necessary

Legal Guardian Initials

Participant's Initials

LEGAL GUARDIAN AND PARTICIPANT NEED TO INITIAL ABOVE AND SIGN BELOW

Signature of Legal Guardian

Date

Signature of Participant

Date

REFUND AGREEMENT

I, , guardian of , have read and understand the Refund Policy: "Refunds will not be given after 5p.m., the first Friday in May." The full policy is located in the Licensed Program Handbook and the Winter/Spring Thornton Activities Guide.

Signature of Legal Guardian

Date

I have read and understand the payment policy found in the Spring Break Camp, Escape to Adventure and Counselor Cadet addendum. I understand that a $15 late fee will be assessed for any deposit program payment made 5 days late. If payments are two weeks past due and/or habitually late, I understand that my youth's space will be forfeited.

Signature of Legal Guardian

Date

If youth is not picked up 5 minutes after the program ends for the day, staff will start making necessary phone calls from your information form. A youth will never be left alone in the classroom.

You will be charged $1 per minute that you are late
Payment must be made at the front desk before your youth can return to camp
You will be given a receipt for your payment. You must show this receipt to camp staff at sign in
Consistent and/or extended instances of late pick-ups may result in forfeiture of youth’s spot in the program without a refund
If the guardians or emergency contacts can not be reached 30 minutes after camp has ended, staff will then turn the youth over to the police department and Adams County Social Services. Every reasonable effort will be made to contact the guardians or authorized contact people before this time

Signature of Legal Guardian

Date

SUN PROTECTION AUTHORIZATION SHEET

I hereby authorize a camp staff member to supervise and/or assist in applying sunscreen to: .

The City of Thornton provides Rocky Mountain brand sunscreen for all participants. If your youth can not wear this brand, please provide him/her with a labeled personal bottle of sunscreen.

SELECT ONE

I agree to allow the camp staff to use Rocky Mountain brand sunscreen on my youth. I do not want the Rocky Mountain brand sunscreen to be used on my youth and I agree to supply my youth with sunscreen to be applied according to the instructions below.

Camp staff supervise/assist with the application of sunscreen to bare surfaces including the face, tops of ears, bare shoulders, arms, legs, back and tops of feet. Staff supervise/assist the application of sunscreen to all exposed skin. Sunscreen is applied when we plan on being outdoors for more than 30-minutes and reapplied every hour.

If you feel this guideline is not sufficient for your youth, please indicate specific instructions below

Signature of Legal Guardian

Date

Attachments

Please download the following forms which need to be filled out by the parent/guardian as well as the youth's physician and attach the completed forms below. These forms are required for camp participation.

If you have existing forms that are already filled out and valid for the upcoming sessions, you do not need to fill out new forms. You can simply attach the existing forms to this submission. Please make sure that the forms you are submitting are valid for the upcoming sessions. For example, if you are submitting an immunization record form, please make sure that the immunizations listed on the form are up to date and valid for the upcoming sessions.

If you do not have these forms filled out at time of submission, they can be filled out and emailed in later or a physical copy can be dropped off.

Colorado Immunization Requirements (Informational Only)
Colorado Allergy And Anaphylaxis Form
Colorado Asthma Care Plan
Colorado Immunization Record Form
General Health Appraisal Form
Medication Authorization Form

General Health Appraisal

Medication Authorization

Colorado Allergy And Anaphylaxis

Colorado Asthma Care Plan

Colorado Immunization

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