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Flying Fingers Camp offers a variety of group and mentoring programs for children including:
Our goal is to Provide a continuum of highly specilaized services that encourages growth and independence in our recreational and educational programs. Develop the most innovative programs that utilize the most dedicated, highly educated and well trained staff available. Provide resources and support to both our immediate neighbors, as well as the Deaf community at large. Please contact us for a comprehensive list of our services. Camper Application FLYING FINGERS CAMP SUMMER REGISTRATION 2007 Camper’s Name: ______________________________________________________ Camper’s Address _____________________________________________________ STREET CITY ____________________________________________________________________ STATE ZIP HOME PHONE NUMBER: _________________________________ CELL NUMBER: _________________________________________ E-MAIL: ________________________________________________ Camper’s Date of Birth: ___________________ AGE: _________ SEX ____ T-SHIRT SIZE: Children’s S___ M___ L ___ Adult’s S___ M ___ L ___ XL___ Adult XXL ___ XXXL ____ (available for $3.00 extra sent with registration) PLEASE ONLY CHECK THE WEEK(S) THAT YOU ARE ACTUALLY PLANNING TO ATTEND. HAVE THE ABILTY TO PAY FOR, AND/OR HAVE ARRANGED PAYMENT FOR FROM OTHER SOURCES. WEEK 1 AUGUST 20- AUGUST 24 __________________ WEEK 2 AUGUST 26- AUGUST 31 __________________ A $75 NON-REFUNDABLE REGISTRATION DEPOSIT MUST ACCOMPANY THIS SHEET OR IT WILL NOT BE PROCESSED! THE DEPOSIT FOR ONE WEEK IS $75, AND FOR TWO WEEKS IS $150 ________________________________________________________________________ FOR OFFICE USE ONLY Registration fee paid _____ Transportation _____ Balance _____ Application _____ Emergency _____ Fin/Aid _____ Photo Release _____ Medications _____ Sliding scale _____ Financial Aid _____ Information _____ Balance _____ FLYING FINGERS CAMP APPLICATION FORM- 2007 Camper Name:________________________________ Nickname: ______________ Sex: ___M ___F Date of Birth: ______________ Age: ___________________ Height: ___________ Eye Color: ___________ Hair Color: ______________ Father/Guardian Mother/Guardian Name_________________________ Name __________________________ Address: _______________________ Address: ________________________ ______________________________ ________________________________ ______________________________ ________________________________ Phone ________________________ Phone ___________________________ Business Phone _________________ Business Phone ____________________ Cell Phone _____________________ Cell Phone ________________________ Must provide 2 names and numbers Emergency Contact Name: ________________________________________ Relationship to camper ___________________________________________ Emergency contact home phone ____________________________________ Work _________________________ Cell _______________________ Emergency Contact Name: ________________________________________ Relationship to camper ___________________________________________ Emergency contact home phone ____________________________________ Work _________________________ Cell _______________________ Please fill out application for each camper you intend to enroll ENROLLMENT AGREEMENT- READ CAREFULLY We will confirm your registration or wait list placement by mail. This confirmation will include a bill for the balance due. Please note that in fairness to families on the waiting list, you must pay on time or your space will go to the next child on the waiting list. During camp, your child’s picture may be taken for use in a variety of publications. By signing the application below you are giving full consent, without limitations or reservations to Flying fingers Camp to publish any photos, audio or video in which your child appears while enrolled in Flying Fingers Camp programs. If you do not wish to consent to a photographic release, pleas attach a written statement requesting an exemption from this release. The $75 deposit is not refundable once enrolled in our camp. ________________________________________________________________________ Parent/Guardian Signature Date Flying Fingers Camp Transportation Form – 2007 The following information will help us to determine your camper’s bus stop and pick-up /drop off times. Camper’s Name: ___________________________________ Pick up and Drop off Address: Number, Street & City __________________________ (must be the same) ______________________________________________________ Phone # pick up: _____________________ Phone # drop off: ____________________ PICK-UP RELEASE 2007 The following person(s) are authorized to pick up my child(s) _____________________ from Flying Fingers Camp Name Address Phone Number Relationship I understand that only those persons listed above will be authorized to pick up my child. I further understand that those persons listed above will need to provide picture identification such as a driver’s license/State Identification card or Passport. Parent/Guardian Signature _______________________________ Date ______________ Name (please print) _____________________________________ ________________________________________________________________________ LUNCH I understand that lunch will not be provided for my child. I will send a cold lunch with my child each day unless told otherwise. ______ (Initials of parent or guardian) Flying Fingers Camp Emergency Treatment Release Form- 2007 RELEASE I hereby release the FFC of Queens County, Flying Fingers Camp and it’s employees of any responsibility or liability for any injury and/or illness derived from participation in the Camp Program. I acknowledge the conditions set forth above and agree with their contents in their entirety. ___________________ Initials of parent of guardian. I, hereby give permission for my camper to participate in any off site field trips, which are part of the day camping program. _____________ Initials of parent of guardian. I, hereby give the flying Fingers Camp, Inc. (FFC) administration, and the medical personnel selected by the Camp Director (or his/her designee) permission to order X-rays, routine medical tests, and medical treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child, the below identified camper. I understand that the Camp will make reasonable attempts to communicate with me prior to medical treatment in non-life threatening and other non-emergency situations, but that in accordance with the preceding paragraph, medical examination and treatment will be performed without necessarily communicating with me first of in life threatening and other emergency situations, even without attempting such communication. I give consent for transportation to a medical facility (by ambulance or camp vehicle) in the event of an emergency. I understand that the permission I have given by signing this form is a material inducement to acceptance of my child as a camper. I also confirm that I have given the Camp a complete and accurate medical history of my child. _________________ Initials of parent of guardian. Camper’s name ________________________________________________________ Sign: __________________________________ ______________________ Signature of parent/guardian Date Witness: _________________________________ _______________________ Signature of witness Date FLYING FINGERS CAMP PARTICIPANT INFORMATION 2007 Participant’s Name _________________________________________________ Participant’s Age _______________________ Date of Birth ___________ Please answer the following questions pertaining to your child’s strength and areas in need of development. This information will be used by the Camp Director and the staff to develop program activities that will be appropriate for the campers. It will assist in making his/her experience as comfortable as possible. Your honest assessment will be most helpful since you know your child better than anyone. Supports Needed Does your child have special needs such as toilet assistance, a behavior plan, dressing or feeding assistance, etc? If yes, please explain: Verbal Expression How does participant communicate? (Ex: sign language, gestures, communication board, oral) Physical Condition/Mobility Describe general mobility, coordination and conditions in which participant may need assistance: Additional Information/Concerns: (i.e. behavioral, adjustments, transitions) Please give a brief description of your child’s behavior, their ability to transition from activities, and any other information: Amplification What amplification if any does participant use? ____ Hearing Aid ____ Cochlear Implant ____ No amplification If there is any additional information you feel will be helpful to the staff at Flying Fingers Camp, please provide the information below. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ FLYING FINGERS CAMP HEALTH HISTORY AND EXAMINATION FORM –2007 Pages 1 and 2 are for parent/guardian to complete and sign. Pages 3 and 4 are for physical to complete and sign. Name of Patient: ___________________________________________________________ Address: _________________________________________________________________ City: ________________________ State ____________ Zip: _____________________ Father/Guardian Mother/Guardian Name_________________________ Name __________________________ Phone ________________________ Phone ___________________________ Business Phone _________________ Business Phone ____________________ Cell Phone _____________________ Cell Phone ________________________ Sex: ___ M ____ F Age: ________ DOB: _____________________ Name of Physician _____________________________________ Address: ____________________________________________ City & zip __________________________________________ Phone # _____________________________________________ Emergency Contact (s) if child is sick and must be picked up from camp: Name_________________________________ Phone # __________________________ Name_________________________________ Phone # __________________________ ALLERGIES List all known Medication Allergies Describe reaction and management of the reaction ___________________ _________________________________________ ____________________ _________________________________________ Food Allergies ____________________ __________________________________________ ____________________ ___________________________________________ Other Allergies- includes plant, animal, insect, asthma, etc. ___________________ __________________________________________ ___________________ __________________________________________ Restrictions- List all that apply Dietary ________________________ Activities: ___________________________ _______________________________ ____________________________________ _______________________________ ____________________________________ General Health Question – 2007 Please explain any yes answers on the spaces provided. DOES YOUR CAMPER: Current History of Problem A) Asthma _______ _________________________ B) Diabetes _______ _________________________ C) Frequent Colds _______ _________________________ D) Pneumonia _______ _________________________ E) Lung/ Breathing Problems _______ _________________________ F) Seasonal Allergies/Other _______ _________________________ G) Ear Infections _______ _________________________ H) Frequent Headaches _______ _________________________ I) Serious Skin Problems _______ _________________________ J) Gum Problems _______ _________________________ K) Dental Problems _______ _________________________ L) Hypertension _______ _________________________ M) Heart/Circulatory Problems _______ _________________________ N) Stomach/Digestive Problems _______ _________________________ O) Kidney/ Urinary Problems _______ _________________________ P) Pica (eats inedible objects) _______ __________________________ Q) Hepatitis B Carrier _______ _________________________ R) Seizure Disorder *** _______ _________________________ *** Please complete the enclosed seizure form to provide us with details regarding your child’s seizure disorder. Medical Insurance Information: Name of Policyholder: ___________________________________________ Relationship to Camper: __________________________________________ Provider: _______________________________________________________ Policy Number: __________________________________________________ Group Number: __________________________________________________ To my knowledge this Health History Form is complete and accurate. The person herein described has permission to engage in all Camp activities except as noted. _____________________________________ __________________________ Signature of parent/guardian Date PHYSICIAN’S EXAMINATIONS- 2007 (TO BE COMPLETE AND SIGNED BY A LICENSED PHYSICIAN) Name of Patient: ____________________________________ I have examined the individual named on this form. Date of last examination:_________________________________ EXAMINATION RESULTS (N=NORMAL) In my opinion this individual ___ is _____ is not able to participate in all camping activities. They may NOT participate in the following activities: ___________________________________________________________________________________________________________________________________________________________________________________________________ The individual is under the care of a physician for the following reasons: ________________________________________________________ _________________________________________________________________ Diagnosis(s): ______________________________________________________ __________________________________________________________________________________________________________________________________ MEDICATIONS: __________ This individual takes NO prescribed medications on a routine basis. _________ The following medications are ordered for the person named on this form. (If a person is on any medications that will be administered during camp, even ibuprofen, a prescription must accompany medications. The prescription must specify the hour of day for administration ex. 12:00 pm not lunchtime. The prescription must also give specific instructions for administration ex. Grind pill, open capsule, takes with food, etc.) Medically prescribed diet: _______________________________________________________________ Treatment (s) administered at camp: _______________________________ ________________________________________________________________ Known Allergies: _________________________________________________ IMMUNICATION RECORD (EITHER FILL THIS SECTION OUT OR SEND, A CHART COPY/PRINTOUT) Flying Fingers Camp Financial Aid Application Please complete this form and mail it with the 2007 Summer Camp Application Registration form by May 1, 2007 to: Flying Fingers Camp, PO Box 750851 Forest Hills NY 11375-0851 Please include a $50 non-refundable deposit and include a copy of your most recent tax form 1040 Flying Fingers Camp Financial Aid program is designed to help as many young people as possible experience summer day camp. Applicants may be awarded tuition assistance for the program, based on family need and available financial aid funds. Flying Fingers Camp Committee will select and notify financial aid recipients no later than June 30, 2007. All information provided in this application will be kept strictly confidential. Name of Participant: ___________________________________M_______F_________ Address: __________________________________________________________________ City: ______________ State: __________ Zip: ________ Phone #: __________________ Parent(s)/Guardian(s) Name(s): _______________________________________________ Occupation of Parent/Guardian: _______________________________________________ Total household annual gross income: ______ less than $9,999 _______ $10,000-$19,999 _______ $20,000-$29,999 ______ $30,000-$39,999 _______ $40,000-$49,999 Number in Household __________ Ages of Children in Household: ________________ Amount of Financial Aid Request: $_________________ Deposit included: $_________________ Many organizations provide funding for young people to attend summer camp. Have you sought out financial aid from any other sources? _________________________________________________________________________ _________________________________________________________________________ Please explain why you are applying for financial aid? Attach an extra sheet of paper if necessary. ________________________________________________________________ ________________________________________________________________________ |
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