Splash Camp Registration Summer 2019
Registration Form for Children 6 - 10
M-F 8am-4pm • Aftercare Available!
June, July and August 2019
802.296.2850 ex 106 | www.uvacswim.org
Email address *
Camper Name *
Your answer
Camper Age *
Special Requests:
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
What swimming level is your child? *
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Parent/Guardian *
Your answer
Home Phone *
Your answer
Work Number
Your answer
Cell Number *
Your answer
Best way to reach you during camp hours *
Heath Concerns/Other Comments
Your answer
If your child has a one on one in school, we would require you to provide a caregiver that will assist your child throughout the day. Please indicate. *
Required
Camp Fees:
Camp Dates:
Please check all that apply
Member Full Day
Non-member Full Day
Member Half Day
Non-Member Half Day
Lunch Package
Aftercare
Week 1 June 10 - 14 "Feathers, Nests and Nature Patterns"
Week 2 SOLD OUT (Wait list only)
Week 3 June 24 - 28 "Stomp Around"
Week 4 July 1,2,3 and 5 "Gnomes and Fairies"
Week 5 July 18 -12 "Youkoso Japan: Welcome Japan!"
Week 6 July 15 -19 "All American! Baseball with American Girl Doll Jamboree!"
Week 7 July 22 -26 "Around the World"
Week 8 July 29 - Aug 2 "Junk Yard Band"
Week 9 Aug 5 - 9 "Neverland!"
Week 10 SOLD OUT (Wait List Only)
Comments:
Your answer
Bonus Camp Aug 26, 27 & 28 TBD
How did you hear about us?
Photo Waiver *
Required
UVAC Health and Emergency Contact Form
Child's Physician:
Your answer
Physician Phone Number
Your answer
Child's Dentist
Your answer
Dentist Phone number
Your answer
In the event we cannot reach a parent please list an alternative Emergency Contact:
1. Name: *
Your answer
1. Phone: *
Your answer
1. Relationship: *
Your answer
2. Name:
Your answer
2. Phone:
Your answer
2. Relationship
Your answer
Does your child have any special needs? *
If yes, please write below what they are and how we can make sure he/she has the best camp experience possible
Your answer
Does the camper have any medical conditions that would affect his/her level of participation in the camp? *
If yes, please list:
Your answer
Will the camper need to take any medications during camp hours? NOTE: Counselors cannot administer medication and children will need to self-administer any and all medications. *
If yes, please list:
Your answer
If your child is allergic or suffers from any of the following please check:
Does your child carry a bee sting kit? NOTE: *Counselors cannot administer bee sting kits. *
*
Required
Pick-up permissions:
In addition to self please list all persons allowed to pick up your child (Photo ID will be needed) *
Your answer
Waiver:
As a parent of the aforementioned camper applicant, I understand and agree to the following: All the information in the Health and Emergency form will be kept confidential and only accessed to ensure the safety and functionality of the campers and the camp. In the event that we are unable to reach a parent/guardian or an emergency contact during an emergency while at UVAC, I hereby give my permission to the UVAC staff and/or medical personnel to take emergency measures as needed. I authorize the Head Counselor or their designate to act for me according to their best judgment in any emergency. I fully acknowledge that even after reasonable safety precautions have been taken, some activities such as swimming, hiking, and other outdoor activities may result in injuries for which the UVAC facility and staff should not be held responsible. By adding your name below you are agreeing to this waiver. *
Your answer
When your form is submitted the registration process has started! An email confirmation that your form went through will be promptly sent. Then within 48 hours you will receive a 2nd email confirming your camp dates, balance due, along with online payment instructions. Payments are expected within two weeks to ensure your space is reserved.

Questions? Contact Karen Cox: 802-296-2850 x106 kcox@uvacswim.org
A copy of your responses will be emailed to the address you provided.
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