2017 KCSCEP/Alban Summer Camp May 30*‐August 4 Enrollment Packet Packet contains: Program Overview Enrollment Form Permission/Agreement Form CONNECT/LINK Acceptance Information Policies & Procedures Child Medical Form Please read all information carefully and fill out the enrollment form completely. Sponsored by: Kanawha County Schools Community Education Program 142 Marshall Avenue, Dunbar, WV 25064 304‐766‐0378 FAX (304) 766‐0389 [email protected] Website: kcscep.kana.k12.wv.us *pending school ending no later than May 26 Welcome to KCSCEP Alban Summer Camp 2017
Serving students who were in Kindergarten through Fifth Grade in 2016-2017 school year. Thank you for choosing the KCSCEP Alban Summer Camp at Alban Elementary for your summer care. Please keep
this sheet for future reference.
Summer Third Base Operation Hours
Summer Third Base 2017 runs Monday through Friday from May 30 (pending school ending no later than May 26)
through August 4. The hours are 7:00 a.m. to 5:40 p.m. Summer Third Base will be closed on June 20 for West Virginia Day and July 4 for Independence Day observances. There will be no discount for those days.
Application
Please complete the application, leaving no blank spaces. (For example, if your child has no allergies, write in
“none” or “N/A”.) List anyone other than parents or guardians allowed to sign your child out. An address and
phone number is required for each authorized person. Please note that a photo ID is required for anyone picking
your child up for the first time or if the director in charge does not recognize the person, parents included. This is
for your child’s safety. Sign and date places indicated on the form.
Fees
There is a $30 non-refundable registration fee per family required for enrollment. Tuition is a flat $125.00 per
week per child payable the first day your child attends each week. There is a late fee of $5.00 per day due until
tuition is paid in full. Be advised that all accounts must be paid in full by Friday, in order for your child to return
the following Monday. We accept cash, check or money order. Make checks payable to KCSCEP (Kanawha
County Schools Community Education Program). We also offer ACH payments through Tuition Express. See the
director for information about this program. There is a $25.00 returned check fee.
Connect or Link is accepted. You must present a current certificate identifying KCSCEP/Alban Summer Camp
(30208647) as “PROVIDER” on the first day your child attends or you will pay the weekly fee until we have this
documentation.
Late Pick Up Fees
Pick up is 5:40 p.m. After this time, there is a $1.00 per minute late fee assessed and payable at time of pick up.
All fees must be paid by Friday in order for your child to return to Summer Third Base the following Monday. Habitual lateness is grounds for dismissal from the program.
Check In & Check Out Procedure/PROCARE
All children MUST be checked in and out by the parent or designated person each day. NO drop-offs. A
child will not be released without your authorization. Send a note or call in the event a non-designated person will
be picking up your child. A photo ID will be required. At pick up, inform the staff of your arrival, check your child
out and gather his/her belongings while the staff calls for your child.
Meals
Breakfast, lunch and an afternoon snack will be provided. Please do not send extra snacks with your child. This is
for the protection of students who have food allergies or dietary restrictions.
Medication
KCSCEP staff do not administer over the counter medication. Prescription medications may only be given by
trained staff. Please see the summer camp site director if your child will need to have prescription medication administered during summer camp. We follow KCS policies for dispensing prescription medications, which includes
having a doctor’s order and having medication in the original bottle or container it was dispensed in with clear and
precise dosing directions.
Child Medical Form
KCSCEP Summer Camps are licensed through West Virginia Department of Health and Human Resources. They
require that we have a Child Medical Form for each child enrolled in Summer Camp. A form for your child’s physician to complete is provided in this packet, or you may bring a comparable form from your child’s physician. This
form is required for enrollment. If you submitted one last year for our summer camp, check with the director to see
if it is still on file. If so, then you will not need to submit a new one, but please review the form for any changes in
emergency contact information.
Program Overview
KCSCEP Summer Camp offers your child a safe, structured environment, with many activities to keep them engaged. There will be a variety of recreational and educational activities. Swimming may be offered once per week
and the cost for swimming is included in your tuition. You must sign the permission form included in this packet.
Discipline
Rules will be posted. Staff will review expectations with the children. The program operates under the guidelines
of Kanawha County Schools and follows the same discipline code of conduct, but we don’t follow KCS IEPs or
504s. All students are expected to listen to and respect the staff. Failure to follow these rules or staff instruction may result in your child being suspended from the program, with no refund of fees. Continued behavioral problems may result in expulsion from the program. Parents will be made aware of problems or poor behavior early on so as to avoid these drastic measures.
Dress Code
The Kanawha County Schools dress code (copy on file) will be followed for summer camp. Please review this policy. Because we will be playing outside and doing arts and crafts and other projects, we recommend students wear
old play clothes and shoes. We recommend sending an extra change of clothes with your child. Students may wear
tennis shoes or sandals with backs, but tennis shoes are required for outside play. NO FLIP FLOPS OR ATHLETIC SLIDES. Please note that children may bring flip flops/slides on swim days to be worn at the pool.
What to Bring
Each child should bring a backpack or bag, labeled with his or her name, to hold their personal belongings. On
swim days, please send your child’s bathing suit and a towel. Please send sunscreen for your child to apply under
staff supervision for outside play and swim days. KCSCEP is not responsible for any lost, stolen or broken
items. Label all personal belongings. Students may NOT bring electronic devises (i.e., ipads, tablets) If your child
has a cell phone, it must be kept in his or her backpack. You may call the summer camp phone if you need to speak
with your child. For safety reasons, students may not use personal devices or cameras to take photos of themselves
or other students during camp.
Contact Information
You may reach us at Alban Elementary School 304-722-0234. Please call if you are running late, especially if there
is traffic jam or accident causing your delay. The site address is 2030 Harrison Avenue, St. Albans.
Questions/Grievances
Please speak with your camp’s site director if you have any questions or concerns during summer camp. If you feel
your questions or concerns have not been resolved by the director, please contact the KCSCEP office at 304-7660378.
We are looking forward to a great summer!
Kanawha County Schools Community Education Program
2017 SUMMER CAMP
Child Care Family Registration Form
A new form must be completed each program year. One form per family. Photo ID required for child pick up. Child(ren) must have been
enrolled in grade K through 5 in 2016-2017 school year to enroll in Summer Camp. Registration Fee is $30 per family.
Check the Summer Camp you are registering for:
 Alban Summer Camp  Elk Summer Camp  Flinn Summer Camp
Have you enrolled a child in a KCSCEP childcare program before? No
 Yes If yes, which site? ____________________________
Name of Child(ren)
Child #1 Full Name
Child #3 Full Name
Child #2 Full Name
Parent/Guardian Information
This section is for information about the legal mother, father, or guardians of the child(ren) and serves as the emergency contact/authorized pick up information. You must provide the name, physical address and a telephone number for each parent/guardian in order for your Enrollment to be accepted. Copies of
all legal documents pertaining to custody, restraining orders, etc. must be on file with the Site Director. (All documents may be reviewed by the KCS legal
department at any time.)
Parent/Guardian 1:
Mother
Father
Grandparent
Foster Parent
Other ____________________________________________________
First Name: _____________________ M.I.: ________ Last Name: ________________________________ Date of Birth: ____________________
Street Address: _____________________________________ City: _________________________________ State: ____ Zip Code: ___________
Occupation/Employer: __________________________ Work Address: ____________________________________________________________
Home Landline Phone: _______________________ Cell Phone: ___________________________ Work Phone: ___________________________
Email address: ___________________________________
Marital Status: Married
Divorced
Separated
Single
Driver’s License or State ID #: ___________________________ Last 4 Digits of Social Security #:_________________________
Mark all that apply:
Child lives with this parent/guardian This parent is an emergency contact. This parent is limited in or not authorized to pick up — see court papers.
Parent/Guardian 2:
Mother
Father
Grandparent
Foster Parent
Other ____________________________________________________
First Name: _____________________ M.I.: ________ Last Name: ________________________________ Date of Birth: ____________________
Street Address: _____________________________________ City: _________________________________ State: ____ Zip Code: ___________
Occupation/Employer: __________________________ Work Address: ____________________________________________________________
Home Landline Phone: _______________________ Cell Phone: ___________________________ Work Phone: ___________________________
Email address: ___________________________________
Marital Status: Married
Divorced
Separated
Single
Driver’s License or State ID #: ___________________________ Last 4 Digits of Social Security #:_________________________
Mark all that apply:
Child lives with this parent/guardian This parent is an emergency contact. This parent is limited in or not authorized to pick up — see court papers.
Account Responsibility
Please indicate who is responsible for tuition. One account per child/family. If you are receiving assistance through CONNECT or LINK, you are responsible for any co-pay
fees. If CONNECT or LINK deny payment or you become ineligible, you will be charged the private pay rate for any week not covered.
Name of Responsible Party: _______________________________________________________________________________________________
I agree to follow all KCSCEP Policies and Procedures and all Summer Camp rules and requirements.(Enrollment indicates acceptance)
SIGNATURE:______________________________________________ Date: _____________________________________
(Parent/Guardian)
Kanawha County Schools Community Education Program 142 Marshall Avenue Dunbar, WV 25064 304‐766‐0378 FAX 304‐766‐0389 [email protected] Website: kcscep.kana.k12.wv.us OFFICE USE ONLY
_____ Registration complete in Procare
_____ Registration fee paid
Information About Child or Children
Child #1: First Name: _______________________ Middle: ______________________ Last Name: ________________________
Name Child Prefers to be called: ___________________________ Grade/Class: ______________ Age: __________________
Date of Birth: _____________________________ Gender: Male Female
Last 4 digits of SSN# :_____________
Allergies (if none, write “none”): ________________________________________________________________________________
List any medical conditions, medications, and/or special attention your child may require (if none, write “none”):
_________________________________________________________________________________________________________
Physician Name: ____________________________________________ Phone: _______________________________________
Physician Address: _________________________________________________________________________________________
Dentist Name: _______________________________________________ Phone: _______________________________________
Dentist Address: ___________________________________________________________________________________________
Child #2: First Name: _______________________ Middle: ______________________ Last Name: ________________________
Name Child Prefers to be called: ___________________________ Grade/Class: ______________ Age: __________________
Date of Birth: _____________________________ Gender: Male Female
Last 4 digits of SSN# :_____________
Allergies (if none, write “none”): ________________________________________________________________________________
List any medical conditions, medications, and/or special attention your child may require (if none, write “none”):
_________________________________________________________________________________________________________
Physician Name: ____________________________________________ Phone: ________________________________________
Physician Address: _________________________________________________________________________________________
Dentist Name: _______________________________________________ Phone: ________________________________________
Dentist Address: ____________________________________________________________________________________________
Child #3: First Name: _______________________ Middle: ______________________ Last Name: ________________________
Name Child Prefers to be called: ___________________________ Grade/Class: ______________ Age: __________________
Date of Birth: _____________________________ Gender: Male Female
Last 4 digits of SSN# :_____________
Allergies (if none, write “none”): ________________________________________________________________________________
List any medical conditions, medications, and/or special attention your child may require (if none, write “none”):
_________________________________________________________________________________________________________
Physician Name: ____________________________________________ Phone: ________________________________________
Physician Address: _________________________________________________________________________________________
Dentist Name: _______________________________________________ Phone: ________________________________________
Dentist Address: ____________________________________________________________________________________________
Photography/Video and Sound Recording
If you do not wish your child(ren) to be photographed or be recorded by video and/or audio devices, please indicate below.
Photographs and audiovisual recordings are used for security purposes and/or for KCS publications/website to inform parents
about our activities. By not initialing, you are giving permission for them to be photographed and/or audio/video taped.
I do not want my child(ren) to be photographed. Initials ___________
I do not want my child(ren) to be recorded by video and/or audio devices. _________
Emergencies/First Aid
KCSCEP staff has permission to administer first aid and/or transport my child in the event of an emergency.
_____________________________________________
SIGNATURE OF PARENT/GUARDIAN
_____________________________
DATE
Other Emergency Contacts & Authorized Pickup Persons
Do not list parents/guardians from page 1! Parents/Guardians are always contacted first in an emergency. You must list at least one person who is not a parent/guardian who can be contacted in the event of an emergency or illness if the parents/guardians cannot be reached.
Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center, able to take
responsibility for the child(ren) in case the parents/guardians cannot be contacted and should be at least 18 years old. You must provide
the name, physical address and a telephone number for each emergency contact in order for your Enrollment to be accepted.
Contact/Pickup #1 First Name: ____________________________ MI: _______ Last Name: ______________________________
Physical Address (Street, City, State Zip): ________________________________________________________________________
Occupation/Employer: ____________________________________ Email: _____________________________________________
Home Phone: ______________________ Cell Phone: _________________________ Work Phone: _________________________
Relationship to Child: ________________________________________________________________________________________
Please mark all that apply. This person will not be authorized unless you check the box.
Emergency Contact
Authorized to pick up the following children: ___________________________________________________________
Contact/Pickup #2 First Name _____________________________ MI: _______ Last Name: ______________________________
Address (Street, City, State Zip): _______________________________________________________________________________
Occupation/Employer: ____________________________________ Email: _____________________________________________
Home Phone: ______________________ Cell Phone: _________________________ Work Phone: _________________________
Relationship to Child: ________________________________________________________________________________________
Please mark all that apply. This person will not be authorized unless you check the box.
Emergency Contact
Authorized to pick up the following children: ___________________________________________________________
Contact/Pickup #3 First Name: ____________________________ MI: _______ Last Name: ______________________________
Address (Street, City, State Zip): _______________________________________________________________________________
Occupation/Employer: ____________________________________ Email: _____________________________________________
Home Phone: ______________________ Cell Phone: _________________________ Work Phone: _________________________
Relationship to Child: ________________________________________________________________________________________
Please mark all that apply. This person will not be authorized unless you check the box.
Emergency Contact
Authorized to pick up the following children: ___________________________________________________________
Contact/Pickup #4 First Name: ____________________________ MI: _______ Last Name: ______________________________
Address (Street, City, State Zip): _______________________________________________________________________________
Occupation/Employer: ____________________________________ Email: _____________________________________________
Home Phone: ______________________ Cell Phone: _________________________ Work Phone: _________________________
Relationship to Child: ________________________________________________________________________________________
Please mark all that apply. This person will not be authorized unless you check the box.
Emergency Contact
Authorized to pick up the following children: ___________________________________________________________
Contact/Pickup #5 First Name : ____________________________ MI: _______ Last Name: ______________________________
Address (Street, City, State Zip): &______________________________________________________________________________
Occupation/Employer: ____________________________________ Email: _____________________________________________
Home Phone: ______________________ Cell Phone: _________________________ Work Phone: _________________________
Relationship to Child: ________________________________________________________________________________________
Please mark all that apply. This person will not be authorized unless you check the box.
Emergency Contact
Authorized to pick up the following children: ___________________________________________________________
2017 KCSCEP Summer Camp Permission Form and Agreements
I hereby grant permission for my child(ren) to use all the play equipment and participate in all of the activities, including water
activities and swimming, associated with Summer Camp. I will send sunscreen for my child to apply daily, under staff
supervision, for outdoor activities.
KCSCEP may transport my child(ren) to a swimming pool if one is not on site. I will send sunscreen, towel and a bathing suit
for my child on swim days.
I understand that my child must have tennis shoes for outside play and flip flops or athletic slides may only be worn at the
swimming pool on pool day.
I understand the KCS Community Education Program or its staff is not responsible for anything that may occur as a result of
false information given by a parent or legal guardian at the time of enrollment.
I agree that the KCS Community Education Program and its staff are released of any liability in connection with medical treatment and unavoidable accidents.
I agree to check my child IN and OUT each day to ensure safety for my child(ren), other children enrolled in the program and
the staff.
I understand the KCSCEP will not be responsible for any lost, stolen or broken items that my child/ren may bring from home.
I have read and understand the explanation of how discipline will be handled and that the program operates under the guidelines of Kanawha County Schools and follows the same discipline code of conduct. I understand that KCSCEP does not follow
Kanawha County Schools IEPs or 504s.
Call 304-766-0378 if you have any questions about the above statements before signing this form.
PARENT/GUARDIAN APPROVAL: As the parent or legal guardian of the below named child(ren), I approve of and agree to
abide by all of the conditions stated above in order to participate in the KCSCEP Summer Camp.
Child(ren) Name ________________________________________________
_________________________________________________
Parent Signature ______________________________________________
Phone ______________________________Date _____________________
ATTENTION: CONNECT OR LINK PARTICIPANTS
KCSCEP Summer Camp accepts CONNECT and LINK. However, a certificate you may have had for Third Base
or On Deck, or for last summer, cannot be accepted. We must have a current certificate for the specific summer
camp.
It is the parent/guardian’s responsibility to get a new Summer Camp child care certificate from CONNECT
or LINK. You must have a child care certificate that lists the specific KCSCEP summer camp (KCSCEP/Alban,
KCSCEP/Flinn or KCSCEP/Elk). A new summer camp certificate must be on file with us and cover the first day
your child(ren) attends or you will be billed the weekly private pay rate for each child.
You are responsible for paying your copay amount on the first day of each week or the late payment fee will apply.
If CONNECT or LINK deny payment or you become ineligible, you will be charged the private pay rate for any
week not covered.
NOTICE OF NONDISCRIMINATION
Applicants for admission and employment, students, parents, employees, and sources of referral of applicants for admission and employment are hereby notified that the Kanawha County School District does not discriminate on the basis of race, color, religion, national origin, sex, age, or disability in admission or access to, or treatment or employment in, its programs and activities. Any person having inquiries concerning the Kanawha County School District’s compliance with the regulations implementing Title IX or
Section 504 is directed to contact: Title IX: Title IX Coordinator, Kanawha County Board of Education, 200 Elizabeth Street, Charleston, WV 25311-2119, phone 348-1379; Section
504: Section 504 Coordinator, Kanawha County Board of Education, 200 Elizabeth Street, Charleston, WV 25311-2119, phone 348-1366. These persons have been designated by
the Kanawha County School District to coordinate the efforts to comply with the regulations implementing Title IX and Section 504.
KCSCEP 2017 Summer Camp Policies & Procedures
Child/Children Name: _________________________________________________
Program Site: _______________________________________________________
ALL TUITION IS DUE THE FIRST DAY OF EACH WEEK
OR THE FIRST DAY THE CHILD ATTENDS EACH
WEEK. We accept check, cash or money order. When
paying with cash, please have exact change or expect
any overpayment to be a credit balance on your account.
You may pay in advance for weeks of care. All checks
must be payable to KCSCEP (Kanawha County Schools
Community Education Program) and the MEMO line must
contain child’s name and Program Site. Counter checks
are not accepted. ACH withdrawals and online payment
are also available through Tuition Express. See the director for an application.
The fee is based on the number of days KCS is in session, not the number of days your child is present in the
program. It is a weekly fee; there are no daily rates. A
late fee of $5.00 will be assessed each day until your
account is paid in full. ALL tuition must be paid in full by
the last day of the week in order for your child to attend
the following week. If tuition and late fees are not paid
by the last day of the week, your child may not return
to the program until the tuition is paid in full.
There is a $30 per family registration fee. The weekly
private pay rate for Summer Camp 2017 is $125 per child
per week. You only pay for the weeks you use, so you
pay the full amount for any week where your child(ren)
attends at least 1 day. Summer Camp will be closed on
June 20 (WV Day) and July 4 (Independence Day) and
there is no reduction in fee those weeks. In the event that
something would cause the camp to be closed 2 or more
days, there would be a discount given at that time.
There is a $25.00 fee for all checks returned for insufficient funds. All fees will be due, payable by cash, to bring
the account current. A second returned check will result in
CASH ONLY for all future payments made by you. Your
child may not attend the program until all fees due
are paid in full. Every effort, up to and including magistrate court, will be made to collect the returned check
amount and fee.
If you receive assistance through WV DHHR from
CONNECT or LINK, you must have your certificate
with the KCSCEP site name listed as the provider on
the first day of attendance, which should be on or
after the certificate start date. You must sign weekly
time sheets and pay weekly co-pays to keep your
account in good standing. Any days of service not
paid by CONNECT/LINK due to a lapse in these procedures or due to a notice of ineligibility will result in
your account being billed the private pay rate. Payment is due the first day of the week you attend and
will be subject to the late payment fee if not paid
when due.
For Summer Camp, an authorized person must come
inside to check in and check out your children. ALL
CHILDREN MUST BE PICKED UP BY YOUR SITE’S
CLOSING TIME. NO EXCEPTIONS! If you arrive past
the closing time, a late pick up fee of $1.00 per minute,
not to exceed $75, is due at time of pick up. Please call if
you are running late so that the staff will know that someone is on their way. Otherwise, if your child has not been
picked up by closing time, we will begin calling people on
the pick-up list. If your child is not picked up and we cannot reach you or anyone on your list, we will call the authorities. Please note that habitual lateness is grounds for
dismissal from the program.
One enrollment form per family. Please complete every
line on the enrollment form. Write “N/A” if not applicable.
Please provide complete names, addresses and phone
numbers for all the people listed on your enrollment form
who may pick up your child. This information is required
by WV DHHR. People listed on your child’s enrollment
form are the only persons that will be allowed to sign your
child out. Parent must notify the Site Director of additional
pick-up persons either verbally or by note. Do not share
your PIN numbers with anyone. Each person must have
his or her own unique PIN numbers.
If the Site Director suspects alcohol use or substance
abuse by the person picking up the child, an alternate
person on your child’s enrollment form will be contacted
for pick up.
Should an emergency situation such as a power outage,
water leak or outage, gas leak, etc. occur and closure is
needed, parents/guardians will be contacted to pick up
their children.
KCSCEP staff DO NOT administer over the counter medications. Prescription medications may only be given by
staff with the approval of the KCSCEP Director and staff
must receive training from a school nurse.
Occasionally, pictures or video/audio recordings are
taken of our KCSCEP program and shared with the website and other programs or publications. If you prefer your
child not participate, please note this on the Registration
form.
Third Base provides a snack to all students each day. If
your child has any food allergies or diet restrictions,
please have your child’s physician fill out the Special Dietary Needs forms (see your site director for these forms).
The Site Director has the discretion to decide if personal
items, such as toys and games, may be brought to the
program. If these items are permitted, they are brought at
your own risk and with the understanding that KCSCEP
and Kanawha County Schools are not responsible for any
lost, stolen or broken items. Students may not use cell
phones to make calls, text or access the Internet during
the program. Cell phones must be kept in the child’s
backpack or bag. Personal electronic devises, such as
tablets and iPads, are not permitted The site may provide
access to the Internet (ex: computer lab, KCSCEP iPads)
under the direct supervision of program staff who have
completed the KCS 24-Hour Internet training.
Fees for late payments and late pick-ups will be enforced.
Site Directors may not waive late fees.
Failure to adhere to program policies may result in dismissal from the program. All students are expected to
listen to and respect the staff. Failure to follow the
rules or staff instruction or other behavior issues
may result in your child being suspended from the
program, with no refund of fees. Continued behavioral problems may result in expulsion from the program. We will make you aware of any poor behavior or
problems early on so as to avoid these drastic measures.
In order to make sure your account is in good standing,
please let your Site Director know if you plan to withdraw
your child from the program. If you have a credit balance
of $10 or more, it will be reimbursed to you. If you have a
balance due, including any late fees, please pay before
withdrawing. Every effort, up to and including magistrate
court, will be made to collect unpaid tuition and fees. You
may not return to the program until any outstanding balance is paid.
Please see the Site Director with any questions or concerns or you may call the Program Coordinator at 304766-0378.
I have read and understand the policies and procedures
for KCSCEP Summer Programs.
______________________________________
Parent/Guardian Signature
______________________________________
Date
CC:
Parent/Guardian
KCSCEP Office
KCSCEP TBM-PP 3/2017 Summer Camp