SUMMER CAMP REGISTRATION
FORM
Choose the week(s) attending: July 18 – 22, 2016
and/ or
July 25 - 29, 2016
Name of Child
(FIRST NAME)
(MI)
(LAST NAME)
Nickname
ADDRESS
City:
State:
Zip:
Birth Date (MM/DD/YYYY):
Age:
Gender:
School child attends during the school year:
Circle T-Shirt Size for Youth Camper:
Grade (as of Aug 2016):
YOUTH SIZE: S M L
ADULT SIZE: S M L XL
FAMILY INFORMATION
 Please check here if your child is currently enrolled in Asheville Parks & Recreation Programs.
*Please list both parents/guardians below and check who to contact for payments and questions
 NAME of Parent or Legal Guardian
(FIRST NAME)
Home Phone: (
(LAST NAME)
)
Cell: (
Employer:
Hours:
Relationship
)
Work Phone: (
ADDRESS
)
City:
Zip:
 NAME of Parent or Legal Guardian
(FIRST NAME)
Home Phone: (
(LAST NAME)
)
Employer:
Cell: (
Hours:
Relationship
)
Work Phone: (
ADDRESS
)
City:
Are there any court-authorized restrictions related to custody or visitation?
If yes, please describe & supply documentation:
PROGRAM COMMUNICATION TOOLS
In an attempt to foster more effective program communication please indicate if we can e-mail or text you:
E-mail: Yes  No  Email Address:
Text Message Yes 
No 
Phone Number:
FOR OFFICE USE ONLY: Received Parent Handbook?
Yes 
No 
Staff Initials:
Zip:
EMERGENCY CARE INFORMATION:
Name of Child’s Doctor:
Phone:
Office Address:
Name of Child’s Dentist:
Phone:
Office Address:
Hospital Preference:
I hereby give permission to Asheville Parks & Recreation and LEAF Community Arts to secure emergency medical, dental,
and/or emergency surgical treatment, and to provide emergency transportation for the above named minor child while in care.
Non-emergency medical treatment or elective surgery is not included in this authorization.
Signature:
Date:
HEALTH INFORMATION ABOUT YOUR CHILD
Does your child have any allergies and/or diet restrictions? If yes, please specify:
Is your child taking medication regularly?
If yes, please specify:
Does your child have any chronic illness or health problem? (i.e. asthma, frequent earaches, etc.)
Do you have any other concerns about your child’s health? Please specify:
If the site staff is not able to reach either parent or guardian, who should be contacted?
Name:
Relationship:
Phone:(H)
Phone:(W)
Name:
Relationship:
Phone:(H)
Phone:(W)
Name:
Relationship:
Phone:(H)
Phone:(W)
When the parent or guardian is not available to pick up your child, what responsible persons can your child be released to?
*(Must be over 18 years old)*
Name:
Relationship:
Phone:(H)
Phone:(W)
Name:
Relationship:
Phone:(H)
Phone:(W)
Name:
Relationship:
Phone:(H)
Phone:(W)
*Prior arrangements must be made when an unauthorized person will be picking up your child. Call the site coordinator to
make these arrangements. Picture ID will be checked on all unfamiliar persons.
SUMMER CAMP MEALS
Would you like your child to participate in our FREE Lunch program? Yes 
Will your child be bringing their own lunch? Yes  No 
No 
(Special diets require doctor’s note.)
LEAF Schools & Streets in Partnership with Asheville Parks & Recreation
This summer, July 18 - 22, 2016 and July 25 - 29, 2016 LEAF Schools & Streets and Asheville Parks & Recreation are thrilled to
collaborate again to present the third annual LEAF Summer Camp! LEAF Camp welcomes all rising first through fifth graders
for a week full of daytime adventures through creative and performing arts.
Kids will step into the magical world of LEAF in a week filled with variety of fun activities. LEAF Summer Camp will re-create
the beloved festival experience for kids as they participate in dance workshops, healing arts, face painting, drumming
workshops, hula hooping, singing, Dj dance parties, circus fun, costume galore, youth performances and more!
During LEAF Camp, kids will learn about global cultures, friendship, self-confidence and empowerment through the
performing arts! For an hour each day, kids will learn and explore with a performing local artist. Through this intimate
learning experiencing, kids will transform into performing superstars by the end of the week, with a final performance for
families and community members. For the first week of camp, youth will host a final performance of their talents, Friday
22nd, at the Dr. Wesley Grant Sr., Southside Center. Campers of the following week will have a chance to perform at the
second annual LEAF Downtown on Saturday, July 30th at the LEAF Community Arts Stage!
LEAF Camp is open to youth from communities all over Asheville and Buncombe County and is intended to be accessible and
affordable for all families, with price tiers designed to respect different families’ financial situations. The camp will run during
the weeks of July 18th thought 22nd and July 25th through 29th, 8:30am-5:30pm at the Dr. Wesley Grant Sr., Southside
Center, located at 285 Livingston Street, Asheville, NC, 28801.
I hereby give permission to Asheville Parks & Recreation and LEAF Community Arts, for my child to do each of the following:

Participate in a walking trip or to be transported in a vehicle for a field trip.

Participate in developmentally appropriate, supervised activities outside of fenced playground / play area.

I certify that I have read, understand, and accept the following representation, stipulations and hereby waive for
myself, my personal representative, heirs and next of kin, and on behalf of my child: ALL CLAIMS, WHICH I MIGHT HAVE
AGAINST LEAF, ANY OTHER PROVIDERS OF FACILITIES AND ANY OF THEM IN COMBINATION, and their officers, directors,
agents, employees and contractors, for injury, accident, illness, property damage, death or other occurrence arising in any
manner whatsoever out of my participation in activities sponsored by LEAF and Asheville Parks & Recreation. FURTHERMORE, I
agree to indemnify, save and hold harmless LEAF and Asheville Parks, Recreation & Cultural Arts from any and all loss, costs,
damages, expenses, and attorney’s fees arising out of my participation, or the participation of persons who accompany me, in
LEAF Summer Camp related activities.
Signature:
Date:
MEDIA RELEASE
I, _________________________________________ (print subject’s name), grant permission to the City of Asheville and its
legal representatives AND LEAF Community Arts and assigns, the irrevocable and unrestricted right to use, publish and
broadcast my photograph(s), likeness and voice for trade, advertising, and any other purpose and in any manner and
medium; and to alter the same without restriction. I hereby release the City of Asheville and its legal representatives and
LEAF Community Arts and assigns from all claims and liability relating to said photograph(s), likeness and voice.
Signature: __________________________________________________________________
Address: _________________________________________________
City: __________________________________ State: _________ Zip: _________________
Phone: Email: _______________________________________
_ I acknowledge that I am over the age of 18
................................................................................................
If subject is under 18:
I, _________________________________________ (print name), am the parent/legal guardian of the individual named
above, I have read this release and approve of its terms.
Signature: _________________________________________Date: _____________________________________________
LEAF Camp Performing Arts Residency Preference
Your child will participate in a Performing Arts Residency each week, with a final performance for parents and community
members at the end of the week to showcase what they have learned. The following fun and interactive residencies may be
offered to campers. Spend the week getting in the groove with hip hop dance, feel the rhythm in African Drumming or connect
to the rich culture of Costa Rica learning traditional songs and dances. Please indicate your first two choices by writing a 1 by
your first choice and a 2 by your second choice for each week they are attending:
Week 1: ___Break Dance
___African Drumming
___Costa Rican Song & Dance
Week 2: ___ Hip hop Dance
___ African Drumming
___Costa Rican Song & Dance
If enrolling through LEAF, please mail form back to 377 Lake Eden Road, Black Mountain, NC 28711.
Currently enrolled youth in Asheville City Parks & Recreation programs should contact
Seth Jackson at (828) 259-5483, or [email protected] with registration questions.
DISCIPLINE AND BEHAVIOR MANAGEMENT POLICY
Asheville Parks & Recreation youth 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 & RESPECT FOR SELF, OTHERS, & THINGS…
1.
Keep hands, feet, and objects to yourself.
2.
Treat other children, staff, and visitors with respect.
3.
Follow the instructions of your group leaders.
4.
Always stay with your group.
5.
Be kind to the environment & 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 & behavior management policy:
WE DO…
1.
2.
3.
4.
5.
6.
Praise, reward, encourage, and listen to children.
Reason with & set limits for the children.
Provide explanations related to the child’s understanding.
Model appropriate behavior.
Provide natural & logical consequences for misbehaviors.
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 program staff to encourage more appropriate behavior. For safety reasons, certain inappropriate behavior cannot be tolerated.
The following are behaviors, which may result in a child’s suspension or termination from the program:
AVOID…
1.
2.
3.
4.
5.
6.
7.
Hurting others or self.
Leaving designated area without permission.
Running away from staff.
Destruction of property.
Repeated cursing or profane language.
Threatening violence.
Jeopardizing the health or safety 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 a child to return to the program.
DISCIPLINE OCCURENCES/CONSEQUENCES:

Verbal Warning from the counselor and/or Site Director

Discipline report written by the counselor or Site Director
o
May or may not have a follow-up call to parent/guardian by Staff
o
Camp suspension for 1-5 days, staff will speak with parents/guardians

Meeting with camper’s parent/guardian
o
Camp suspension for 1-10 days, staff will meet with parents/guardians

Camper removed from camp
o
No refund is given with this occurrence
o
Meeting with Program Supervisor of Summer Playground/Teen Programs
I, the undersigned parent/guardian of __________________________(Child’s full name), have received and read the Discipline &
Behavior Management Policy for Asheville Parks & Recreation youth program (LEAF Summer Camp) at the Dr. Wesley Grant Sr.,
Southside Center. The program staff is available to discuss the policy with me, and answer any questions I might have about this
policy. I agree to abide by this policy as a condition of my child’s enrollment in the youth program, and will discuss the basic rules
of behavior with my child.
____________________________________
Signature of Parent
____________
Date
__________
Staff initials
DISCIPLINE AND BEHAVIOR MANAGEMENT POLICY
**Parents, please keep this copy at home and review with your child.
Asheville Parks & Recreation youth programs are based on recreational activities provided in large group settings,
with transitions from one program area to another. In order to ensure the care, welfare, safety and security of all
youth program participants, children are expected to follow the basic rules listed below:
CARE & RESPECT FOR SELF, OTHERS, & THINGS
1.
Keep hands, feet and objects to yourself
2.
Treat other children, staff and visitors with respect
3.
Follow the instructions of your group leaders
4.
Always stay with your group
5.
Be kind to the environment & play spaces
Staff will use praise and positive teaching techniques to encourage appropriate behavior, and all programs will
practice the following discipline & behavior management policy:
WE DO...
1.
2.
3.
4.
5.
6.
Praise, reward, encourage and listen to children
Reason with and set limits for the children
Provide explanations related to the child’s understanding
Model appropriate behavior
Provide natural and logical consequences for misbehaviors
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 program staff to encourage more appropriate behavior. For safety reasons, certain
inappropriate behavior cannot be tolerated. The following are behaviors which may result in a child’s suspension or
termination from the program:
AVOID
Hurting others or self
Leaving designated area without permission or running away from staff
Destruction of property
Repeated cursing or profane language
Threatening violence, verbally or through posturing
Jeopardizing the health or safety 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 a child to return to the program. The consequences listed below do not
necessarily occur in the order presented based on the severity of incidents or a child’s behavior.
DISCIPLINE OCCURENCES/CONSEQUENCES:

Verbal Warning from the counselor and/or Site Director

Discipline report written by the counselor or Site Director
o
May or may not have a follow-up call to parent/guardian by Staff
o
Camp suspension for 1-5 days, staff will speak with parents/guardians

Meeting with camper’s parent/guardian
o
Camp suspension for 1-10 days, staff will meet with parents/guardians

Camper removed from camp
o
No refund is given with this occurrence
o
Meeting with Program Supervisor of Summer Playground/Teen Programs