2 Bridges Kids!

Spring Recess Camp 2014 Application

Please check that you have included all of the following forms:
Items to be submitted Student Enrollment Form Child & Adolescent Health Examination Form Medical Treatment Authorization Form Code of Conduct Travel Form $50 Check or money order to Two Bridges Neighborhood Council

February 25, 2014

Dear Parents, NEW! 2 Bridges Kids! Spring Recess Camp 2014 2 Bridges Kids! is offering a Spring Recess camp program to enrich the lives of children while schools are out of session. Our program provides innovative curriculum embodying physical fitness, recreational art, social studies, literacy and STEM activities. Camp will be held April 14, 2014 through April 18, 2014, for youth ages 6-12. Enrollment is $50 per student. We will begin at 8:00am and end at 5:00pm Monday through Friday, in the Goldie Chu Community Room at 82 Rutgers Slip. Campers are recommended to eat breakfast prior to arriving to camp, lunch will be provided. Parents are advised to provide a daily snack. Our daily schedule is as follows: 8:00-9:00am 9:00-10:00am 10:00-12:00pm 12:00-1:00pm 1:00-2:00pm 2:00-3:00pm 3:00-3:30pm 3:30-4:30pm 4:30-5:00pm Arrival/Quiet games Warm-up activity Outdoor Physical Activity (weather permitting) Lunch (provided by Two Bridges) Daily Activity (Arts& Crafts and Literacy) STEM activity Snack (provided by guardian) Indoor Physical Activity Cool Down Activity/Dismissal

If interested, please complete the attached registration packet and return to the Community Programs Office, located on the ground floor of 82 Rutgers Slip. If you wish to submit this form electronically, please scan and e-mail to Roxana@twobridges.org. Registration is due before April 4th, but spaces are extremely limited, so please submit your forms as soon as possible to ensure your childs space in the program. We look forward to meeting you and your child! Sincerely,

Roxana Ancher 2 Bridges Kids! Director

2 Bridges Kids! Spring Recess 2014 Student Enrollment

STUDENT INFORMATION
Student Name _____________________________ ______________________________ ____
First Last MI

Mailing Address ______________________________ _______________________ _________

Building Number, Street, and Apartment City and State Zip

Home Phone (____) _______________ Emergency Contact ____________________________ Birthdate ____/____/________ Emergency Phone (____) _______________________

Sex (circle one) Male Female Other

Relationship to Student ________________________

Parent/Guardian Name ________________________ Signature _______________________ Parent/Guardian e-mail _________________________________________________________ Signature of Student _______________________________ Date _______________________
Two Bridges periodically uses photographs or video or audio footage or testimonials of students for local or regional publicity or educational purposes. By signing above, I give permission for TBNC to use such reproductions for educational and publicity purposes.

Check box if you decline permission for photos or video to be taken.

STUDENT DROP-OFF & PICK-UP

Persons Authorized for Child Drop-off/Pick-up ______________________________________
Name

If a parent will not be at drop-off/pick-up to sign the child into and out of the program, only an authorized adult (above the age of 18), may transport the student home. Only individuals listed here will be allowed to leave with the student. Drop off will be at 3pm, pick-up will be between 5:30pm and 5:45pm. Any student that is picked up late more than 2 times will be released from the program to make room for additional students. Signature of Authorized Individual __________________________________ Date _________ Check box if Emergency Contact is allowed to pick up student.

Witness Signature: _________________________________Printed Name:__________________________

2 Bridges Kids! Medical Treatment Authorization Form

This form grants temporary authority to a designated adult to provide and arrange for medical care for a minor in the event of an emergency, where the minor is not accompanied by either parents or legal guardians, and it may not be feasible or practical to contact them. Childs Full Legal Name: _____________________________________Home Address: ______________ Date of Birth:________/_________/_____________ Sex (circle one): Female Male Other Information for Medical Treatment Physicians Name and Location of Practice: ________________________________________________________________________________ ______ Physicians Phone # (if known): (____)_______________________ Medical Insurer/Health Plan: __________________________ Policy #: __________________________ Allergies to Medications: ________________________________________________________________ Allergies (Other): ______________________________________________________________________ Please note all conditions for which the child is currently receiving treatment: ________________________________________________________________________________ ______ Note any other significant medical information: ________________________________________________________________________________ ______ AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S) I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for 2 Bridges Kids! staff (hereafter Designated Adult) to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Designated Adult to summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Designated Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel. Signed this _____day of________, 2013.

Parent / Legal Guardian Signature: ___________________Printed Name: _________________________

2 Bridges Kids! Code of Conduct

2 Bridges Kids! believes in creating a safe learning environment that encourages creativity, responsibility, and an environment of mutual respect. We have developed this code of conduct in order to provide a clear understanding of expectations. Students and parents/guardians must sign this form in order to participate.

CODE OF CONDUCT
1. All students must submit a completed and signed Medical Consent Form. No student is allowed to carry medication on their person, and we do not store medication on site. 2. Students should attend and be actively involved in all scheduled activities as art of 2 Bridges Kids! Some areas of the camp site are off-limits to students (e.g. 2nd floor classroom, downstairs hallway, South Street garden patches, etc.) unless under appropriate instructor supervision. 3. Visitors to 2 Bridges Kids! must check-in upon arrival with the Two Bridges Tower security guard, Site Director, or tutors. 4. Students must remain at 2 Bridges Kids! until the end of the day. Students may not leave the program without prior written or verbal notification by the parent/guardian to the staff. Students must be signed out by the designated parent/guardian as listed on the Enrollment Form. 5. Students are expected to follow the directions of staff. All students are under the supervision of the Director and other staff present. 6. Students should respect the property of others and be responsible for themselves. Deliberate destruction or removal of facilities/equipment is not permitted. Financial responsibility for any damages caused by deliberate destruction will be assumed by the student and/or parents/guardians. The same applies to the property and personal items of other participants. 7. Students should treat all others and themselves with respect. Aggressive, abusive, vulgar or violent language and behavior towards others (e.g. threats, insults, fighting, discrimination, etc.) are not permitted. 8. Possession, distribution, or use of fireworks, weapons, knives, or items that can be used as a weapon are not permitted at 2 Bridges Kids! facilities or on field trips. 9. Possession, distribution, or use of alcoholic beverages, illegal drugs, tobacco products, and unauthorized prescription drugs are not allowed at any Two Bridges event and must be reported to law enforcement. 2 Bridges Kids! reserves the right to conduct a search of a students outer clothing, luggage, personal belongings, and furniture being used by a student if there is reasonable suspicion that the participant has drugs, alcohol, or weapons. 10. Animals and pets are not allowed at 2 Bridges Kids! After School unless needed to accommodate a disability or as part of an organized program, or through specific authorization from the Director. Animals that are used as part of 2 Bridges Kids! should always be provided with proper care. 11. Electronic and mechanical devices (e.g. cell phones, pagers, walkie-talkies, video games, radios, mP3 players, laptops, etc.) are not allowed at camp unless they are needed as part of an organized activity, or with authorization from the Director or staff. Without authorization, these items will be confiscated and returned to the participant/parent/guardian at the end of the day.

CONSEQUENCES
Unacceptable behavior (as defined within this Code of Contact or through a review process by Two Bridges staff) will result in consequences to the participant. Consequences may include: 1. Early release from 2 Bridges Kids! Camp 2. Restitution or repayment of damages 3. Denial of future participation in 2 Bridges Kids! school or summer sessions, and/or events sponsored by Two Bridges Neighborhood Council 4. Releasing the student to the appropriate law enforcement agency and/or the proper authorities. NOTE: Any conduct not specifically covered by this Code of Conduct, but deemed inappropriate by staff responsible will be viewed as a violation and appropriate action will be taken. If an infraction occurs, the staff in charge will provide appropriate communication to parents/guardians.

SIGNATURES (Both signatures are required for all students under 18 years of age.)
I have read and understand the above Code of Conduct and will abide by the expectations described in the code. I understand that if I act inappropriately I will have to accept responsibility for my actions that may result in the consequences listed above. Student Signature _________________________________________ Date _______________ I have discussed and reviewed this Code of Conduct with my child. I understand that failure to abide by this Code of Conduct may result in the consequences listed above which includes no monetary or in-kind refund. In the event that this code is violated, I agree to come to 2 Bridges Kids! to pick up my child at the request of the adult in charge. I further understand that I refuse to pick up my child, am unavailable, or fail to make timely arrangements to retrieve my child, 2 Bridges Kids! staff may contact law enforcement or social services to provide necessary protection for a child in need of services. I acknowledge responsibility for all fees/charges that may result form said services. Parent Signature __________________________________________ Date _______________

2 Bridges Kids! Travel Form 2 Bridges Kids! Name of Program ________________________________ CAIMS 82 Rutgers Slip Campsite Address ______________________________ City Manhattan Student Information ______________________________________
Name

00607217 Zip 10002

Trip Date

Trip Destination Two Bridges green spaces Rutgers Slip, Cherry Street, Madison Street, Montgomery Street/Pier 42 @ New York, New York 10002 Seward Park Library @ 192 East Broadway New York, New York 10002

Mode of Transportation Walking

Activity Details (Must specify) Nature Observation & Physical Fitness Activity Reading

Parental Consent O Yes O No

4/14-4/18

4/14-4/18

Walking

O Yes

O No

PARENTAL CONSENT I _______________________________________, as the legal parent/guardian of

(Print Name)

___________________________________, __________, hereby give permission for him/her

(Student Name) (Student Age)

to participate in the trips and activities as indicated on the above itinerary. Signature __________________________________________ Date_____/______/_______

I have enclosed $50 to help pay for lunch/supplies/activity costs.