2 Bridges Kids!

Summer Day Camp 2014 Application

Please be sure to include all of the following items: Items to be submitted Camper Enrollment Form Child & Adolescent Health Examination Form Medication Treatment Authorization Form Signed Code of Conduct Travel Form $25 Check or money order to Two Bridges Neighborhood Council (financial aid is available)

March 14, 2014

Dear Parents, Greetings from Two Bridges Day Camp! Two Bridges Neighborhood Council is planning an exciting opportunity for exploratory learning! Two Bridges Day Camp will be held from July 14 to August 14 2014, for youth ages 6-12, and is fully licensed by the city and state of New York.
This summer, campers enrolled in 2 Bridges Kids! will continue to explore their neighborhood, city, and watershed. Covering ecology, animal behavior, environmental science, and climate change, this summers curriculum will examine issues of environmental justice on the Lower East Side. In addition to designing, conducting, and reporting original scientific research, campers will explore their environment during field trips, outdoor play, and thematic arts and crafts projects. From Yoga and poetry to water quality testing and robotics, campers continue to build critical thinking skills, literacy, and scientific knowledge from previous years programs. We encourage campers who have not yet participated in 2 Bridges Kids! STEM programs to apply as well, since topics covered in this comprehensive, standards-based curriculum are re-taught by our certified staff each year.

We will begin at 8:30am and end at 5:00pm Monday through Friday, in the Goldie Chu Community Room at 82 Rutgers Slip. Campers will be escorted to free breakfast (until 9:15am) and lunch at PS 184. Parents should provide a daily snack. Friday evening, August 15th, we will have a Community Celebration for all campers and their families. We are writing to encourage your child to participate. The camp is FREE for all Two Bridges Tower residents. In addition, if you would like your child to attend 5 field trips around the city, please include payment in the amount of $25 to Two Bridges Neighborhood Council. Financial assistance is available. To register, please fill out the completed packet and sign all permission forms. Packets must be delivered to the Coordinator of Community Programs at 82 Rutgers Slip (second floor). Please register as soon as possible, as space is extremely limited. We hope you will consider this exciting opportunity for your child to learn and grow! Sincerely,

Roxana Ancher 2 Bridges Kids! Summer Day Camp Director

2 Bridges Kids! Camper Enrollment

CAMPER INFORMATION Name ________________________, __________________________
Last First

________
MI

Date of Birth ____/____/________ Sex (circle one)

Male

Female

Home Address ______________________________ _______________________ _________

Building Number, Street, and Apartment City and State Zip

APPLICANT INFORMATION Name of person applying for camper ________________________ Relationship to Camper ____________________ Day Phone (____) _____________ Cell Phone (____) _____________ Email address ___________________ Emergency Contact _________________________ Emergency Phone (____) _____________ Relationship to Camper______________________

Parent/Guardian Name ________________________ Signature _______________________ Two Bridges periodically uses photographs or video or audio footage or testimonials of campers 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. May we use your child in photographs and/or video? Yes No

CAMPER PICK-UP LIST Names of individuals authorized to pick up child who are NOT listed above: Name ________________________ Name ________________________ Name ________________________ Phone ________________________ Phone ________________________ Phone ________________________

If a parent will not be at pick-up to sign the camper into and out of camp, only an authorized adult (above the age of 18), may transport the camper home. Only individuals listed here will be allowed to leave with the camper. Pick-up will be between 5:00pm and 5:15pm. Any camper that is picked up late more than TWICE will be released from the program to make room for additional campers.

Parent/Guardian Signature __________________________________

Date _____________________

2 Bridges Kids! Medication 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. This form should be given to the trip leader or shown to the trip leader and then carried by the designated adult. Childs Full Legal Name: _____________________________________________________________ Home Address: ____________________________________________________________________ Date of Birth:________/_________/__________ Sex (please circle): Female Male Other

Physicians Name and Location of Practice: ________________________________________________ Physicians Phone Number: (____)________________ Medical Insurer/Health Plan: __________________________ Policy #: _______________________ Allergies to Medications/Food: __________________________________________________________ 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! Summer Day Camp 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________, 20__. Parent / Legal Guardian Signature: ___________________Printed Name: _____________________ Witness Signature: _________________________________Printed Name:______________________

2 Bridges Kids! Code of Conduct

Two Bridges Day Camp 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. Campers and parents/guardians must sign this form in order to participate. CODE OF CONDUCT 1. All campers must submit a completed and signed Health History Report and Medication Form (included in your registration packet). No camper is allowed to carry medication on their person. All medications must be turned in to the Head Counselor for secure storage. 2. Campers should attend and be actively involved in all scheduled activities as art of Two Bridges Day Camp. Some areas of the camp site are off-limits to campers (e.g. 2nd floor classroom, downstairs hallway, South Street garden patches, etc.) unless under appropriate instructor supervision. 3. Visitors to Two Bridges Day Camp must check-in upon arrival with the Two Bridges Tower security guard, Camp Director, Health Director, or counselors. 4. Campers must remain at Two Bridges Day Camp until the end of the camp day. Campers may not leave camp without prior written or verbal notification by the parent/guardian to the staff. Campers must be signed out by the designated parent/guardian as listed on the Enrollment Form. 5. Campers are expected to follow the directions of camp staff. All campers are under the supervision of the Camp Director, Health Director, and other staff present. 6. Campers 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 camper and/or parents/guardians. The same applies to the property and personal items of other participants. 7. Campers 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 Two Bridges Campsite 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. Two Bridges Day Camp reserves the right to conduct a search of a campers outer clothing, luggage, personal belongings, and furniture being used by a camper if there is reasonable suspicion that the participant has drugs, alcohol, or weapons. 10. Animals and pets are not allowed at Two Bridges Day Camp unless needed to accommodate a disability or as part of an organized program, or through specific authorization from the Camp Director. Animals that are used as part of Two Bridges Day Camp 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 Camp 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 Day Camp 2. Restitution or repayment of damages 3. Denial of future participation in Two Bridges Day Camp, and/or events sponsored by Two Bridges Neighborhood Council 4. Releasing the camper 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 campers 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. Camper 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 Two Bridges Day Camp 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, Two Bridges Day Camp 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

Name of Camp ____2 Bridges Kids! Summer Day Camp_________ CAIMS # __00607217_______ Campsite Address _82 Rutgers Slip______ Borough __Manhattan____ Zip 10002

Camper Information ______________________________________ Name

Trip Date 7/14-8/14

Field Trip Destination Two Bridges green spaces Rutgers Slip, Cherry Street, Madison Street, Montgomery Street @ New York, New York 10002 Seward Park Library @ 192 East Broadway New York, New York 10002 Union Square Greenmarket @ E 17th St & Union Square W, New York, NY 10003 Museum of Arts and Design @ 2 Columbus Cir, New York, NY 10019 Central Park Zoo @ 64th St and 5th Ave, New York, NY 10021 Brooklyn Childrens Museum @ 145 Brooklyn Ave, Brooklyn, New York 11213 SONY Wonders @ 550 Madison Ave, New York, NY 10022

Mode of Transportation Walking

Activity Details Nature Observation Reading Guided Tour Guided Tour and Workshop Guided Tour Self-Guided Exploration Guided Tour

Parental Consent O Yes O No

7/14-8/14 7/18 7/22 7/29 8/5 8/12

Walking Subway Subway Subway Subway Subway

O Yes O Yes O Yes O Yes O Yes O Yes

O No O No O No O No O No O No

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

(Print Name)

___________________________________, __________, hereby give permission for him/her to participate in the trips
(Camper Name) (Camper Age)

and activities as indicated on the above itinerary. Signature __________________________________________ Date_____/______/_______ I have enclosed $25 to cover the cost of field trips. I am requesting financial aid, and have not included $25. I do not wish for my child to attend these field trips, and will provide at-home care for him/her during the days listed above.