8455 Camden Hwy P.O. Box 186 Rembert, S.C. 29128
Tel: (803)432-2001 Cell: (803)420-1255 Fax: (803)432-2404
E-mail: [email protected] Website: www.raccinc.com
Summer Camp 2017 Registration Form
(Please Read Carefully)
Participating Child’s Information:
First Name: ____________________________ Last Name: _________________________ Male Female
Date of Birth: ______________ Age: _______ Codeword (for child pick up)___________________________
Home Address: ____________________ City: _______________________ State: _______ Zip: __________
Parent/Guardian Information:
Name: __________________________________________
Relationship: __________________________
Primary Phone: ____________________________
Work/Other: ________________________________
Place of Employment: ____________________________ E-mail: ____________________________________
Emergency Contact (if parent/guardian is not available)
Name: __________________________________________
Relationship: __________________________
Primary Phone: ____________________________
Work/Other: ________________________________
Place of Employment: ____________________________ E-mail: ____________________________________
Immunization Records: These are required for children 5 years of age or younger to participate. Please
check one:
 Record on file from Afterschool Program 2016-2017
 Records enclosed
Physician Information:
Name: ____________________________________ Practice Name: __________________________________
Insurance Information:
Plan Name: ________________________________ Group or ID#: ___________________________________
Name of insured: ________________________________ Relationship to child: ________________________
Any pertinent information we need to know about your child (ex. fears, medication, allergies)? _____________
__________________________________________________________________________________________
My child will walk home each day________ (Initial)
My child will be picked up each day________ (Initial)
List authorized adults to pick up your child, including parents. If additional space is needed please use
the back of this page:
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© RACC2017 – Revised 3/30/2017
Parental Consent – PLEASE INITIAL ALL LINES
_____I, parent or guardian for the above individual, hereby gives approval to his/her participation in any activity provided by the
Rembert Community Center. I assume all risks and hazards incidental to such participation including transportation to and from the
program site/activity, and hereby waive, release, absolve, indemnify, and agree to hold harmless the organizers, sponsors, supervisors,
and participants in the activity.
_____I grant permission to managing personnel or other representative to authorize and obtain medical care from any licensed
physician, hospital or medical clinic should the above become ill or injured while participating in the program away from home or
when neither parent is available to grant authorization for emergency treatment. I understand that, if in a medical emergency, I cannot
be reached, the law enforcement personnel will be called to assume responsibility for the child and for contacting the parent.
_____I Grant permission for my child to participate in workshops and classes offered by various agencies through partnerships, i.e.
DSS, DJJ, Clemson Extension Services, and United Way. Note: Classes/Workshops provided would be generated towards that
specific group (ages 3.5 and 13). Older children may be accepted on a case by case basic (Must be school age).
Rembert Community Center‘s programs are based on recreational activities provided in large group settings, with transitions from one
program area to another. In order to insure the care, welfare, safety, and security of all youth program participants, children are
expected to follow the following basic rules:
CARE AND RESPECT FOR OTHERS, SELF & THINGS:
1. Keep hands, feet, and objects to yourself.
2. Treat children, staff, and visitors with respect.
3. Follow instructions of your group leader.
4. Always stay with your group.
5. Be kind to the environment and play spaces.
Please review these rules with your children. Staff will use praise & positive teaching techniques to encourage appropriate behavior,
and all programs will practice the following discipline and behavior management policy:
WE DO:
1. Praise, reward, encourage, and listen to children.
2. Reason with and set limits for the children.
3. Provide explanations related to the child’s understanding.
4. Model appropriate behavior.
5. Provide natural and logical consequences for misbehaviors.
6. Use short, supervised periods of time-out.
When children do not respond to positive behavior management strategies, parents will be notified and will be expected to work with
the program staff to encourage more appropriate behavior. For safety reasons, certain inappropriate behavior cannot be tolerated. The
following behaviors, which may result in a child’s suspension or termination from the program:
AVOID:
1. Hurting others or self.
2. Leaving designated area without permission.
3. Running away from staff.
4. Destruction of property.
5. Repeated cursing or profane language.
6. Threatening violence.
7. Jeopardizing the safety or health of others.
If such misbehaviors occur, parents will receive a disciplinary action notice, and will be expected to support and work with program
staff in order for the child to return to the program.
Thank you for supporting our staff’s effort to ensure the safety and well being of all program participants.
Please sign and complete the following statement for our records:
I, the undersigned parent or guardian of ____________________________________________________ (Child’s full name),
have received and read the Discipline and Behavior Management Policy for the Rembert Community Center Summer Camp Program.
The program staff has discussed the policy with me, and answered any questions I might have. I agree to abide by this policy and
govern myself in according as a condition of my child’s enrollment in the Summer Camp Program, and will discuss the basic rules of
behavior with my child.
_________________________________________________________
Parent/Guardian Signature
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Date
©RACC2017 – Revised 3/30/2017
MEDIA RELEASE
I give permission to the Rembert Area Community Coalition Summer Camp Program without limitation or
obligation, to use photographs, film footage, or tape recordings which may include my child’s image or voice
for purposes of promotion of Rembert Area Community Coalition programs.
I hereby release the Rembert Area Community Coalition Summer Camp Program from any debts, claims
actions, causes of action, demands, suits and all liabilities whatsoever, both in law and in equity, which may
result from the release of the photo.
I represent that I am the parent/guardian of this child and have every right to contract in this regard. I have read
the above authorization and release prior to its execution and I am fully familiar with the contents thereof.
To ensure your privacy, we would like your permission to include your child in these photographs.
Please check:
 My child does have permission for photographs to be used in future promotions or informational
packages put together by the Rembert Area Community Coalition Summer Camp Program.
 My child does not have permission for photographs to be used in future promotions or informational
packages put together by the Rembert Area Community Coalition Summer Camp Program.
Name of Child
Signature of Parent/Guardian
Date
TRANSPORTATION
I give permission for my child to leave the Rembert Area Community Coalition Summer Camp Program site,
participate in authorized trips and to ride in authorized vehicles for the purpose of transportation in connection
with the youth programs. I understand that field trips will be scheduled in advance and parents will be notified
of the details prior to departure.
Please check:
 My child does have permission to leave the Rembert Area Community Center Summer Camp Program
site, participate in authorized trips and ride in authorized vehicles for the purpose of transportation in
connection with the youth programs.
 My child does not have permission to leave the Rembert Area Community Center Summer Camp
Program site, participate in authorized trips and ride in authorized vehicles for the purpose of
transportation in connection with the youth programs.
Name of Child
Signature of Parent/Guardian
Date
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©RACC2017 – Revised 3/30/2017
LATE PARENT POLICY – PLEASE INITIAL LINE
_____I understand the operation hours of this site, I further understand that if I am late picking up my child I
will be charged $5.00 for every 15 minutes that I am late. In the event that if I am late more than twice in
picking up my child from the site, then on the third time, law enforcement will be contacted to assume
responsibility for getting my child home, and the site will close on time. This policy will be enforced.
FEES, DUE DATES, PAYMENT AND REFUND POLICY – PLEASE INITIAL ALL LINES
_____ Rembert Youth Center will be open Monday thru Friday from 8:00am to 4:30pm for summer camp.
There is a $15.00 registration fee for non-afterschool participants. The cost of the summer camp program
for each school-aged child is $15.00 per week. The fee may be paid weekly or bi-weekly. The cost for each
second child will be $12.00 per week and $10.00 per week for each additional child. Fees are to be paid in
advance on Monday for the current week's services. A late fee of $5.00 will be accessed if payment is not
received by the close of business on Tuesday. Fees must be paid prior to service rendered.
Please select if you wish to pay weekly or bi-weekly
I will pay weekly. I understand that payment is due no
later than the close of business on Tuesday.
I will pay bi-weekly. I understand that payment is due
no later than the close of business on Tuesday.
Initial Below
Payments may be made at the following locations:
 The Administrative Office - 8455 Camden Hwy, Rembert SC 29128. The office is opened between
10:00am and 4:00pm, Monday thru Friday.
 Via mail - RACC, POB 186, Rembert SC 29128.
 To the Summer Camp Instructor – Please request a receipt
***For questions or concerns regarding fees, due dates or payments, contact Dr. Juanita Britton @
(803) 420-1255***
_____No refunds or adjustments will be given for days when children do not attend. Exceptions will apply only
if child is admitted into the hospital.
CENTER CLOSINGS
 We will be closed for all major holidays. Please see Holiday Closing Schedule (posted in the Youth
Center).
 The center will be closed for two week during the summer prior to school opening.
I agree to abide by these policies as a condition of my child’s enrollment in this program.
_______________________________________________
Signature of Parent/Guardian
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Date
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