Fillable Bcyfcampjoy Winter2019 Application Fillable (City of Boston)

Fill Online, Printable, Fillable, Blank Bcyfcampjoy Winter2019 Application Fillable (City of Boston) Form

Use Fill to complete blank online CITY OF BOSTON (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Bcyfcampjoy Winter2019 Application Fillable (City of Boston)

On average this form takes 35 minutes to complete

The Bcyfcampjoy Winter2019 Application Fillable (City of Boston) form is 7 pages long and contains:

  • 0 signatures
  • 15 check-boxes
  • 134 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Boston

BROWSE CITY OF BOSTON (MA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Please mail or drop-off original applications to:
Boston Centers for Youth & Families
1483 Tremont Street
Boston, MA 02120
Attention: Roberta Smalls
(617) 635-4920 ext. 2402
INCOMPLETE OR ILLEGIBLE APPLICATIONS WILL NOT BE ACCEPTED.
Enrollment will remain open until all slots are filled.
Completed applications are due September 27, 2019.
Please include a copy of the Camper’s photo you are applying for along with the completed application.
Enclosed medical section and camper immunization form must be completed and signed by a physician.
Saturdays, October 5, 2019-March 28, 2020
CAMPER APPLICATION
CAMP JOY WINTER
2019-2020 CAMPER APPLICATION
CAMPER INFORMATION:
Camper’s Name: ____________________________________________________________________________
Age: __________ Date of Birth: ______/______/______ Gender: Male Female
Home Address: _____________________________________________________________________________
City: ____________________________________________ Zip Code: _______________________________
Camper’s Home Language: ______________________ Race (for State report only): _____________________
Name of Parent/Legal Guardian: _______________________________________________________________
Home Phone: (_________)______________________ Cell Phone: (_________)______________________
Email address: _____________________________________________________________________________________
EMERGENCY CONTACTS:
In case of emergency if parent/guardian is unavailable, please contact:
Contact Name: _____________________________________________________________________________
Home Phone: (_________)______________________ Cell Phone: (_________)______________________
Home Address: _____________________________________________________________________________
City: ____________________________________________ Zip Code: _______________________________
Contact Name: _____________________________________________________________________________
Home Phone: (_________)______________________ Cell Phone: (_________)______________________
Home Address: _____________________________________________________________________________
City: ____________________________________________ Zip Code: _______________________________
BCYF Camp Joy Winter 2019-2020
Camper’s Name: _______________________________________________________________________
EMERGENCY CONSENT AND RELEASE
If a situation arises in which my child is in need of prompt medical attention and I, or my designee (emergency contact),
cannot be contacted, I hereby grant permission to a responsible member of the Camp Joy staff to authorize treatment
for my child.
__________________________________________
____________________________
PARENT/GUARDIAN SIGNATURE
DATE
ACKNOWLEDGEMENT
The undersigned acknowledges that, in consideration of the opportunity to participate in the City of Boston’s
therapeutic recreation program, neither the City nor any of its employees are liable in the event of illness, injury,
accident or death which may occur while my child or the participant is engaged in the program, is traveling to or from
the program, or is engaged in any function of the program. This acknowledgment does not relieve the City or its
employees from claims based on gross negligence, or intentional or reckless conduct.
The undersigned further acknowledges that if any child or the participant does not conform to the standards and
organization of the program or if the directors of the program judge that the behavior of my child or the participant
endangers himself/herself or the welfare of others in the program or the program itself, (s) he may be dismissed from
the program upon written notice.
__________________________________________
____________________________
PARENT/GUARDIAN SIGNATURE
DATE
PHOTOGRAPHIC RELEASE
Please read and sign this photographic release. Please note that it is not necessary for you to sign this portion of the
release for your child to attend Camp Joy. However, it would be to our convenience if you would sign this section.
I hereby give my consent to Camp Joy to photograph my son/daughter without limitation to use such pictures and/or
stories in connection with any of the work of Camp Joy without consideration of any kind and I do hereby release Camp
Joy and Boston Centers for Youth & Families from any claims whatsoever which may arise in said regard.
__________________________________________
____________________________
PARENT/GUARDIAN SIGNATURE
DATE
BCYF Camp Joy Winter 2019-2020
GENERAL INFORMATION:
Does your child use any of the following?
Glasses? Yes No Hearing Aid? Yes No Walker? Yes No Wheelchair? Yes No
Does your child use any other type of adaptive equipment? Yes No If yes, please explain: ______________
_________________________________________________________________________________________________
Does your child have Allergies? Yes No If yes please explain:_______________________________________
Does your child have any dietary restriction?_____________________________________________________________
Will it be necessary for your child to take medication during the camp day? Yes No
**If your child requires medication during camp hours you must complete the Authorization to Administer
Medication to a Camper form, and attend a mandatory orientation before the child can attend Camp Joy.
Does your child have a sibling attending Camp Joy? Yes No If so, what is his/her name?
_________________________________________________________________________________________________
What school does your child currently attend? ___________________________________________________________
Does your child communicate verbally? Yes No ___________________________________________________
Does your child have allergies? If so, please explain: _______________________________________________________
Does your child need assistance using the bathroom? _____________________________________________________
Has your child ever attended Camp Joy? Yes No What location? ________________________________
Please list any compulsive behaviors and appropriate responses for staff to take: _______________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Please list any other precautions or behaviors that the camp staff should be aware of: ___________________________
_________________________________________________________________________________________________
Please tell us about your child’s swimming ability: ________________________________________________________
_________________________________________________________________________________________________
Can your child participate in other physical activities? Yes No If yes, list any necessary
accommodations:
___________________________________________________________________________________
_________________________________________________________________________________________________
Does your child have a special toileting procedure? Yes No If so please describe:
_________________________________________________________________________________________________
Does your child use a wheelchair? Yes No If so, please identify the level of support needed: ____________
_________________________________________________________________________________________________
BCYF Camp Joy Winter 2019-2020
Camper Application—Medical Section
APPLICATION WILL NOT BE ACCEPTED WITHOUT THIS FORM
COMPLETED & SIGNED BY A PHYSICIAN
Camper’s Name: ___________________________________________________________________________________
Diagnosis: (Medical Term) ___________________________________________________________________________
(Layman’s Term) ___________________________________________________________________________________
Is camper subject to allergic reactions? Yes No If so, please specify: ________________________________
_________________________________________________________________________________________________
Is camper medicated? Yes No
Type: ___________________________________________ Dosage: ________________________________________
Type: ___________________________________________ Dosage: ________________________________________
Time(s) administered: ______________________________________________________________________________
How is medication administered? _____________________________________________________________________
Will it be necessary for camper to take medication during the camp day? Yes No
Is camper subject to seizures? Yes No Are they controlled? Yes No
To your knowledge, is the camper suffering from or has (s)he recently been exposed to any contagious disease?
______________________________________________________________________________________________________
_________________________________________________________________________________________________
Does camper have any dietary restrictions? _____________________________________________________________
May camper participate in carefully supervised swimming activities? Yes No
May camper participate in a physical education program? Yes No
Are there any precautions that should be noted? (PLEASE SPECIFY) __________________________________________
_________________________________________________________________________________________________
Does camper live in a group home: ____________________________________________________________________
Camper’s height: _________________________________ Weight: __________________________________________
Does the camper use any other type of adaptive equipment? Yes No
If yes, please explain: _______________________________________________________________________________
Camper/Family Caseworker: __________________________________________________________________________
Agency: ________________________________________ Telephone: ________________________________________
Date of Physical Examination _____/_____/_____
______________________________________________________ M.D.
___________________________________________________
Physician’s Signature (REQUIRED) Print/Type Physician’s Name
BCYF Camp Joy Winter 2019-2020
CAMPER IMMUNIZATION FORM
APPLICATION WILL NOT BE ACCEPTED WITHOUT THIS FORM
COMPLETED AND SIGNED BY A PHYSICIAN
Required Immunization for Campers and Staff
Camper’s Name: ___________________________________________________________________________________
Date of Physical Examination _____/_____/_____
______________________________________________________ M.D.
______________________________________________
Physician’s Signature (REQUIRED) Print/Type Physician’s Name
For Campers & Staff
< 18 years or age
For Campers & Staff
> 18 years of age
Date Issued
Must be completed by a physician
MMR 1
2 doses measles,
1 dose mumps
1 dose rubella
2 doses measles 2
1 dose mumps 2
1 dose rubella
POLIO
> 3 doses of either
inactivated poliovirus
vaccine (IPV) or oral
poliovirus vaccine (OPV). If
mixed schedule or
IPV/OPV was used, 4 doses
are required
No Requirement
DTaP/DTP/
DT/Td
> 4 doses DTaP/DTP/DT or
> 3 doses Td3
A booster dose of Td is
required for all campers
and staff who will be
entering
grades 7 – 10 if it
has been more
than 5 years since
the last dose of
DTaP/DTP/DT;
grades 11 & 12 if it
has been more
than 10 years since
the last does of
DTaP/DTP/DT/Td.
(Tdap is also acceptable.)
> 3 doses
DTaP/DTP/DT/Td.
A booster dose of
Td is required if >
10 years since the
last dose of
DTaP/DTP/DT/Td
vaccine. (Tdap is
also acceptable.)
Hepatitis B
3 does for all children born
on or after January 1, 1992
No requirement
BCYF Camp Joy Winter 2019-2020
COMPLETED APPLICATION CHECKLIST
Before returning this Camp Joy Camper Application, please check (√) to see if the following
sections are accurately completed:
CAMPER INFORMATION COMPLETED
PARENT/GUARDIAN INFORMATION COMPLETED
EMERGENCY CONTACT LISTED (AT LEAST ONE) — Must be different from home telephone number.
EMERGENCY CONSENT SIGNED (parent/guardian signature)
ACKNOWLEDGEMENT SIGNED (parent/guardian signature)
PHOTO RELEASE SIGNED (parent/guardian signature)
GENERAL CAMPER INFORMATION PAGE COMPLETED
CAMPER MEDICAL SECTION COMPLETED—WITH PHYSICIAN SIGNATURE
CAMPER IMMUNIZATION SECTION COMPLETED—WITH PHYSICIAN SIGNATURE
WITHOUT MEDICAL & IMMUNIZATION SECTIONS COMPLETED AND SIGNED BY A
PHYSICIAN YOUR APPLICATION WILL BE RETURNED. PLEASE DOUBLE CHECK
COMPLETE AN AUTHORIZATION TO ADMINISTER MEDICATION TO A CAMPER FORM BY
A PARENT/GUARDIAN IF NECESSARY.
NON-REFUNDABLE FEE: Please make money orders payable to the Foundation for BCYF-Camp Joy.
Payment is due with the completed application.
Parent/Guardian fee is $150.00 per child.
CURRENT IEP (Individual Education Plan): Please send copies of the goals pages of your child’s most
current IEP. A letter from your child’s doctor will be accepted if you do not have an IEP.
PERSONAL CHECKS AND CASH ARE NOT ACCEPTED. NO EXCEPTIONS!
ONLY COMPLETED APPLICATIONS WILL BE PROCESSED!
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Bcyfcampjoy Winter2019 Application Fillable (City of Boston)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 26 March 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document