Registration form tuesday thursday 9: 00 a m. 2: 00 p m. (No groups on Mondays or Fridays) Location

9:00 a.m. – 2:00 p.m.

There are no refunds for absences; however, in extenuating circumstances, such as hospitalization or a family emergency, we can credit the cost of missed days to our other programs.

If you would like to discuss payment plans or financial assistance, please call us at 303-773-3960.

All payments can be made with a personal check (payable to Connect Us) or online. Go to www.connectusnow.org and choose the “Programs” link on the top menu bar.

Payment options — select one:

• 
  I have enclosed a check for full payment in the amount of $___________.
  
• 
  I have enclosed a check for deposit in the amount of $__________.
  
• 
  I have made an online payment of $___________.
  

I request that my child be admitted to Connect Us Summer Camp. I have read and understand the Connect Us refund and cancellation policy.

• 
  To arrange an earlier pick up time, if child/children will be absent or if you’ll be late to pick up, please call us at 303-773-3960 or email programs@connectusnow.org.
  
• 
  If it’s critical that you speak with a staff member during camp hours and you’re unable to reach us at the number above, please call Stephanie Schiff’s cell phone at 303-807-1836.
  
• 
  As a last resort, call Greenwood Community Church at 303-843-0281.
  

• 
  Extra set of clothing in a labeled, zip-lock bag (recommended for younger children in case of accidents)
  
• 
  Epi-pen, inhaler, special snacks for dietary restrictions, etc.—all labeled!
  

• 
  Play clothes-okay to get dirty or stained
  
• 
  Sneakers
  
• 
  Sunscreen-apply prior to arrival each day
  

• 
  Hat or visor
  
• 
  Swim suit & towel (on Thursdays)
  
• 
  Water bottle
  
• 
  Lunch
  

ALLERGY ALERT!

We do not provide snacks with peanut butter, nuts or nut products. Some children have an allergy to nuts, a potentially life-threatening condition. If you provide a snack for your child’s group, please do not bring anything that contains nuts or nut products.

MEDICATIONS, CARDIOPULMONARY RESUSCITATION (CPR):

Connect Us staff will not administer any medication to a child unless it is an emergency, such as an allergic reaction that requires an Epi-pen. Please review the Medical/Emergency Form for details regarding emergency procedures.

Our entire staff is certified in CPR.
SAFETY

The well-being of our participants is our first priority! Groups are staffed and structured to optimize safety and to ensure that every child is nurtured. Our facilitators actively promote an appreciation of personal and cultural differences and expect participants to treat others with kindness and respect. When a conflict occurs between children, we typically address it in the group; allowing children to work on communication and problem-solving skills.
BEHAVIOR

Connect Us programs are all about relationship-building, teamwork and the joy of group play. If a participant isn’t having fun or has a negative attitude, it can be detrimental to the group. Facilitators use a number of strategies to address this and other disruptive behaviors, however, they are not therapists. If behaviors persist, we may suggest that a written Behavior Agreement is implemented with the child. This strategy is highly effective when the same behavior expectations are reinforced at home.

If a child is aggressive toward other children or staff, or is repeatedly disruptive after adult intervention, it may be necessary to remove the child from the program. If we are unable to accommodate a child, we will refund the cost for days he/she did not attend. Connect Us reserves the right to dismiss a participant from our program if we are unable to meet the child’s needs.

COMMUNICATION

At the end of each week, we will email a Weekly Recap which will include highlights and photos from the week and information pertinent to the following week. Parents/guardians are always welcome to speak with our staff at pick-up. If you’d like to discuss your child in depth, please call 303-773-3960 or email programs@connectusnow.org to schedule a meeting.

Your input is critical to our results! If at any time you have questions or concerns or would like us to reinforce anything you’re working on at home, please don’t hesitate to contact us.

Thank you for entrusting us with your child/children!

Parent/Guardian:

Date:

MEDICAL/EMERGENCY INFO and RELEASE FORM

(Please fill out a separate form for each child)

Child’s Name	Birthdate	Grade	School		Primary contact’s name & phone #
PARENT/GUARDIAN INFORMATION
Parent/Guardian:				Parent/Guardian:
Address:				Same Address Address:
City/Zip:				City/Zip:
Home phone: Cell: Work:				Home phone: Cell: Work:
E-mail:				E-mail:
OTHER EMERGENCY CONTACT INFO
Friend/Relative (relationship to Child):				Physician:
Primary phone #:				Physician phone #:
Phone # 2:
List any medical conditions, including illnesses, surgeries, drug reactions or drug/food allergies, special diets, medications, diagnoses or any other concerns or information we should know about your child. You may continue on the back of this page.
PARENTAL CONSENT
As a parent or guardian of a child/children enrolled in a Connect Us program, I authorize the director or staff member(s) into whose care I have entrusted her/him/them permission to perform medical treatment for my child/children as needed. This includes my consent to have Connect Us transport my child/children to a licensed medical facility should the situation require it. I understand that in such a case, reasonable attempts would first be made to contact me or the contacts listed above, with time and conditions permitting. I have included, above or on an attached sheet, information about my child’s/children’s medical history and emergency contacts. I understand that each participant assumes all risks, consequences and potential liability. I hereby release and hold harmless the program site, director and staff members of Connect Us, its employees, volunteers and any other person, firm or corporation charged or chargeable with responsibility or liability from any and all claims by reason of accident, illness, injury or other consequences arising from participation in a Connect Us program. My child has permission to: Participate in all sports and activities (List any exceptions):  Yes  No Eat snacks provided by Connect Us (List any exceptions):  Yes  No Eat gluten, dairy, wheat and soy free snacks (List any exceptions):  Yes  No Be photographed and videotaped for our website; for the purpose of evaluating our program, training our staff or for marketing materials:  Yes  No I have carefully read this agreement and fully understand the contents. I am aware that this is a release of liability on behalf of my child and I sign it of my own free will.
PARENT/GUARDIAN SIGNATURE:						DATE:

AUTHORIZED TO PICK UP CHILD/CHILDREN

Child/Children: _______________________________________________

Authorized Person	Relationship to child	Phone Number

In addition to parent/guardian and emergency contact(s) listed on Medical/Emergency Form, the following people are authorized to pick up my child/children:

I understand that Connect Us will not release my child/children to anyone other than parent/guardian or individuals listed above, nor will Connect Us allow my child/children to leave the premises until they are released to an authorized person.

Parent/Guardian:

Date:

PARENT INTAKE QUESTIONNAIRE

(Please fill out a separate form for each child)

Today’s Date:	Completed By:
Child’s Name: Sex: Birthdate: Grade:

1. 
   How did you learn about this program?
   

2. 
   What are your child’s favorite activities or interests? 
   

3. 
   What are your child’s greatest strengths? What is most challenging for your child? 
   

4. 
   Rate each sentence below from 1 to 4 as it relates to your child during unstructured play time, such as at recess or on a playground.
   

1=Never 2=Rarely 3=Occasionally 4=Frequently

1. 
   ___ Decides what he/she wants to play and recruits peers to join in
   
2. 
   ___ Joins in a sport, activity or game regardless of whom is playing
   
3. 
   ___ Seeks out specific friends and plays whatever they are playing
   
4. 
   ___ Plays alone
   

(5) Using the same scale in question 4, please rate your child on the following:   SCALE
Initiates social interaction	1	2	3	4
Maintains friendships	1	2	3	4
Is cooperative (helpful, gets along with adults and peers)	1	2	3	4
Is flexible (goes with the flow, willing to try new things)	1	2	3	4
Is resilient (rebounds from disappointment, copes well with frustration)	1	2	3	4
Is self-confident (positive about self and abilities)	1	2	3	4
Is empathetic	1	2	3	4
COMMENTS:

6. 
   What would you like your child to gain from participating in our program?
   

Office Use Only

Check# ____________

Online _____________

Amt Paid __________

Date Paid __________

Rec’d by _____________

Summer 2016 Checklist

Participant Name(s):_______________________________________
Indicate all weeks that apply

Week	Dates
1 2 3	7/5 – 7/7 7/12 – 7/14 7/19 – 7/21

Registration Forms:

___ Registration form (pages 1-2)

___ Parent’s Guide to Summer Camp (pages 1-2)

___ Medical/Emergency Form

___ Authorized to Pick Up

___ Parent Questionnaire

Deposit:

___ Paid $50.00 x ____children

Balance due: $ _________

Keep this portion for your records
Balance due: $ _______________

Deposit of $50.00 per child AND registration forms due:

April 15, 2016

Balance due:

May 20, 2016

E-MAIL, MAIL or FAX COMPLETED FORMS:

E-mail: programs@connectusnow.org

Fax: 303-759-0803

Mail: Connect Us, 6940 S. Holly Circle Suite #107, Centennial, CO 80112

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