Vacation 2019/20 Splash Camps Registration Form
Registration Form for Children 6 - 10 years
M-F 8am-4pm • Aftercare Available!
December Camps: Holiday 1 and Holiday 2, 2019, February and April 2020
802.296.2850 ex 106 | www.uvacswim.org

This form has been formatted to ease the creation of weekly checkin and lunch lists... please skip questions that say: "For Office Use Only".
Email address *
Camper's Preferred First Name *
Your answer
Camper's Last Name *
Your answer
Camper's Age *
Special Requests:
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
For Office Use Only
Your answer
For Office Use Only
Your answer
For Office Use Only
Your answer
For Office Use Only
Your answer
What swimming level is your child? *
Pick-up permissions:
Please list SELF, and THEN other adults who have your permission to pick up your child.
Your answer
Guest or Member Account Information:
Camper's Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Self as Parent/Guardian *
Your answer
Home Phone *
Your answer
Work Number
Your answer
Cell Number *
Your answer
Best way to reach you during camp hours *
Help us help your child have the best camp experience possible
Health Concerns/Other Comments
Your answer
If your child has a one on one in school to help support following directions, we would require you to provide a caregiver that will assist your child throughout the day. Please indicate. *
Required
Our goal is for all of our young friends to have a successful experience at camp. If you know your child would benefit from an informal behavior plan with us, please let us know... Kana or Karen will call you to discuss best ways to handle emotional or behavioral issues should they come up.
Camp Fees:
Camp Dates:
Special Note about Holiday Camps: UVAC will close early on Christmas Eve and New Year's Eve (Tuesdays). Therefore, Tuesday will only be half day during holiday weeks. No Camp on Christmas Day or New Year's Day. If "Full Day" is selected the understanding is such: Monday Full Day; Tuesday Half Day; Wednesday NO CAMP; Thursday Full Day; Friday Full Day.
Please check all that apply : please note, pricing is applied based on your current membership status with UVAC
Full Day
Half Day
Lunch Package
Aftercare
Holiday Week 1 : Dec 23 - 27
Holiday Week 2 : Dec 30 - Jan 3
February Vacation Week : Feb 17 - 21
April Vacation Week : April 13 - 17
Comments:
Your answer
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? Counselors can remind a child when it's time to take medication, but cannot administer the medication. Labeled medication will be kept in the Swim School Office, the child can come to the office to take his or her 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 can help retrieve a bee sting kit, but they cannot administer bee sting kits. *
Waivers:
Photo Waiver *
Required
*
Required
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 3-5 business days you will receive a 2nd email confirming your camp dates, balance due, along with online payment instructions. Payments are expected within the week of this confirmation email 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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