PJA-AFTERSCHOOL: Vacation Day Participation Form
SPRING Term & JUNE 2012
KIDSPACE & KIDSPLACE
Spring Term: March 2012 – May 2012
The JUNE Vacation Programs are SEPARATE!
Location: PJA-Kidspace, 9935 NW Durrett Rd, Portland, OR 97229
Inside the Forest Park School Cafeteria
June dates will be at the PJA-Kidscorner location, 6651 SW Capitol
Hwy, Portland, OR 97219
Program Hours: 8:00AM – 6:00PM
Planned field trips will occur between 8:30AM-3PM
Early Starts: NOT Available this term!
VACATION DAY PROGRAM FEES:
Kidspace/Kidsplace PARTICIPANTS –
Vacation Care Tuition participants –
VACATION PROGRAM ACTIVITIES
Please mark the program day
you would like your child/youth to attend…
SPRING Term Dates: at Kidspace location!
Mon, March 26 – Spring Break Program
NO Fieldtrip: Game Show Day – Themed Onsite Activity Day!
A wide assortment of games will be played including bingo, Taboo, make your
own game show, Win Lose or Draw, and more!
Tues, March 27 – Spring Break Program
Fieldtrip to Washington Park for a Treasure Hunt and fun on the playground!
8AM-6PM Program Fee is included in Monthly Tuition for
Spring Term dates ONLY!
Regular Care Tuition participants –
$45 per child/Day;
OR $190 per child for Spring Break Days ONLY!
JUNE Vacation Programs – 8:00AM-6:00PM
$45 per child/Day; Fees apply to all participants!!!
Non-Kidspace/Kidsplace PARTICIPANTS –
$55 per child/Day;
OR $225 per child for Spring Break Days ONLY!
A 10% Sibling Discount is offered to all families with more than one
participating child!
All Participants need to include applicable fees with Participation paperwork!
PARTICIPATION DEADLINES:
ONE Business Week Prior to the Vacation Day for which you are enrolling
Participation forms may be accepted after deadline, if space is available and a
$5 late fee will be added to your bill
Call/Email the Afterschool Dept. Director to inquire about available space,
503.535.3546, [email protected]
TERMS OF PARTICIPATION:
 Participation Authorization Forms MUST be accompanied by the fees in full!
 10% of the Participation Fees are ALWAYS Non-Refundable.
 Participation Authorization Forms MUST be received by the Deadline of one business
week prior.
 Participation Authorization Forms received after the Deadline will be accepted ONLY if
there is space available. Please contact the Director of Afterschool Dept., 503-535-3546,
to find out if we have space available for your child(ren),a $5 Late Registration Fee will
be applied to your bill.
 Cancellation MUST be made in writing; email is acceptable, to the PJA-Afterschool Dept.
Director. Note that 10% of the Participation Fee is Non-Refundable.
 Cancellations made prior to the Listed Deadline, 90% of the Participation Fees will be
refunded. Cancellations made after the Listed Deadline, only 50% of the Participation
Fees will be refunded.
 PJA-Afterschool reserves the right to dismiss a child whose behavior is deemed
inappropriate, in which case, no refunds will be given.
 NO Shows or Same Day Cancellations WILL be charged a FEE on all Vacation Days
with a scheduled Field Trip, Including Vacation Tuition Members. Please call or email AT
LEAST 24-hr in Advance to cancel! Thank you!!
 Be sure to bring a nutritious LUNCH and dress for the forecasted
Wed, March 28 – Spring Break Program
NO Fieldtrip: Grossology – Themed Onsite Activity Day!
Activities MAY include having and icky taste test, making a fake wound and
boogers on a stick, playing musical farts and booger ball as well as making a
worm bin and more!
Thurs, March 29 – Spring Break Program
Fieldtrip to the Oregon Zoo
Fri, March 30 – Spring Break Program
NO Fieldtrip: Backyard Camp-out – Themed Onsite Activity Day!
Activities MAY include making smore’s, building forts, fish printing and lots of
outdoor-style games!
Fri, April 13 – Spring Break Program
NO Fieldtrip: Spies & Secret Codes – Themed Onsite Activity Day!
Activities MAY include teeth print matching, mazes, fingerprint art, a secret
code hunt and more!
Closed Monday, May 28 for Memorial Day!
JUNE Dates: at the PJA-Kidscorner location in SW Portland
Separate cost for these dates for ALL participants!
Thurs, June 14 – School’s Out Program
Fieldtrip to Oxbow Park for a Naturalist lead outing and fun in this great wild
park!
Fri, June 15 – School’s Out Program
NO Fieldtrip: Let’s Bag It – Themed Onsite Activity Day!
Activities MAY include a bag hunt, making exploding bags & water bag bombs,
making bag puppets and gack in a bag, playing sack races and so much more
fun!
weather and planned field trip!
SPACE IS LIMITED.
BOTH pages of this Participation Form are REQUIRED*
* Please complete this participation form in its entirety (front and back), even though you
may have already provided the information requested on your original afterschool
Enrollment Form. We apologize for redundancy however State regulations require us to do
so as this form acts as your participation authorization for our specially planned activities
and/or field trips. Thank you!
GOT QUESTIONS –
Jennifer Merrill,
Director PJA-Afterschool Dept.
503.535.3546 | [email protected]
PLEASE READ – Incomplete Forms WILL BE RETURNED UNPROCESSED!
Please accurately complete ALL requested information below!
RELEASE FORM
SPRING Term & JUNE 2012: KIDSPACE & KIDSPLACE
FAMILY INFORMATION
Parent/Guardian (1)
Alternate Phone
Address
Parent/Guardian (2)
Alternate Phone
Address
Phone
Email
Phone
Email
CHILD/YOUTH INFORMATION
Child (1)
Child (2)
Child (3)
Child (4)
ALLERGY ALERT:
Gender
Gender
Gender
Gender
Does your child have allergies? Y
Grade
Grade
Grade
Grade
N
School
School
School
School
Please list details:
OTHER AUTHORIZED PICK-UP PERSONS; in the event of an Emergency or otherwise
Name (1)
Relationship
Phone
Alternate Phone
Name (2)
Relationship
Phone
Alternate Phone
Medical Provider
Dental Provider
Insurance Company
Phone
Phone
Phone
Provider Number
BY COMPLETING THIS PARTICIPATION FORM, I ALSO AUTHORIZE THE FOLLOWING:
1.) In an emergency situation, I authorize for a representative from PJA-Afterschool Programs to call an ambulance or take my child(ren) to any available physician or
hospital at my expense and to obtain medical treatment for my child(ren). In most emergencies/major injuries, 911 is called, trained EMT’s make the assessment if
transportation to the nearest hospital is required. A PJA-Afterschool employee will accompany the child and Parents/Guardians are notified as soon as
possible.
2.) I authorize my child(ren) to only to be given medication provided by my family in the original container in association with the required and completed medication
administration form (Please contact the Director of Afterschool Dept. to receive this form, 503.535.3546). I understand that administration of Non-Prescription Medication
will also REQUIRE a signed note from my child’s pediatrician!
3.) I authorize for my child(ren) to have sunscreen provided as seen fit by PJA-Afterschool staff, unless otherwise noted.
4.) I authorize Syrup of Ipecac to be administered to my child(ren) ONLY if deemed necessary by the Poison Control operator.
5.) I authorize my child to be photographed for publicity, marketing or news purposes, unless an opt out written request is submitted.
6.) I authorize for PJA-Afterschool Programs to provide transportation for my child. I understand transportation may be provided by PJA-owned bus, Tri-Met (bus, Max,
streetcar, tram, etc…) or by a rented bus service. Seatbelts are required when provided & all other transportation laws are strictly followed and maintained at all times.
Parent/Guardian Signature
Date
(This form is NOT valid unless you sign and date it)
Full Payment by check or credit card MUST be included with registration
TOTAL Full-Day Program Fees:
Vacation Tuition Member*:
(Checks payable to PJA; Visa or MasterCard ONLY)
YES
NO
*Remember – the JUNE Vacation Dates have a cost for ALL participants!
Credit Card Number
Exp
I am attaching a check made payable to PJA
AFTERSCHOOL DEPARTMENT OFFICE ONLY –
Date Received:
Payment Received:
Y
Received by:
Total Fees Received:
Check Credit
$___________
Circle DATES: 3/26; 3/27; 3/28; 3/29; 3/30; - - - 6/14; 6/15
N
VDP
Confirmation Mailed:
Late Fees, if any: