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Summer Registration

Program Registration Form

Memorial Garden

Summer 2015 Registration On-line/By Mail

Will be available March 2015

It is required that you and your child meet with one of our staff prior to registration for an IFA (Initial Family Assessment) if you are new to the Center.  This will alleviate any anxiety or unsure feelings about enrolling and it will help include them in the decision.

 

Registration Fees are non-refundable

Immunization Records MUST be received to guarantee enrollment

 

1.Print form below, fill out one for each child and sign all spaces (please read thoroughly).

2.  Mail with a non-refundable deposit (check or money order) in the amount of $25.00, and payment towards the first week to Sunshine Center in order to hold your spot                                  (See address in contact section).  CAMP MUST BE PAID PRIOR TO STARTING!

3.  Call a few days later to confirm that Sunshine got your form in the mail (Sunshine is not responsible for lost or misdirected mail).

4.  An invoice will be sent to you for the balance with a confirmation.

5.  Deposits will only be returned if the program is full, unless you want to be put on the waiting list.

6.  Programs usually fill to full capacity with a waiting list.                                                           No mail-in registrations are guaranteed until you are notified by Sunshine.

7.  Sunshine will contact you if further information is needed for registration

 

 Asking for financial assistance/sponsorships?  

You must fill out the paperwork—click here for form—

no spot is guaranteed—sponsorships are limited based on funding

 

 

 

 

 

 

 

 

 

 

 

Sunshine Summer Prevention Program Registration Form - 2015

468 Boyle Road, Port Jeff Station, NY  11776 * Phone: (631) 476-3099, Fax:  (631) 476-7680

Date __________________            How did you find out about this program? _________________________

 

Name of Participant___________________________________________  Birth date ___________________

 

Male / Female    Grade Completed ________    School ________________   Age in summer _________  

 

Race/ethnicity: Black ____  White ____ Hispanic ____   Native American _____  Asian _____  Other __

 

Parent(s)/Guardian(s) ___________________________________  Home Phone_________________

 

Mailing Address _______________________________________________  Cell Phone_________________

 

Town, Zip ___________________________________________ Work Phone_________________________

 

Emergency Contact ____________________Phone_______________Alternate Phone___________

 

Email Address (For Invoicing, program Information, newsletters)__________________________________

 

Social Skill Youth Camp Ages 4—11

Please check sessions you are registering your child for:

 

 

Check weeks you are registering this child for    _______  Children 4—11     _______  CIT Program ages 12 & up

 

____ Week 1: July 6 – 10                 ____ Week 2: July 13 - 17                 ____ Week 3 July 20 - 24   

  

____ Week 4: July 27  – 31   

 

Total Weeks you are registering for Social Skills Youth camp    ________  

 

 

Life Skills Teen Camp ages 12 and up

 

Check weeks you are registering this child for _______   Youth ages 12 & up    _______   Preteen program 10 & 11

 

____ Week 1: August 3 - 7           ____ Week 2: August 10 - 14               ____ Week 3 August 17 - 21   

  

 

Total Weeks you are registering for  Life Skills Teen Camp    ________  

 

 

 


Permission Form

 

I understand that if my child has been registered for the Summer Program, the space will be reserved for my child.  Spaces are limited for every program run through Sunshine Center. If you reserve a space for your child, that eliminates the opportunity for another child to come.  There is a $25 non-refundable registration fee required for all participants in all programs.  If you have registered and want to switch programs/weeks for some reason, Sunshine cannot guarantee this unless there are open spaces.  If you have registered and paid for your child and then you need to take your child out of the program for some reason you must give us two weeks notice in order for you to receive a refund.  If you do not notify us, you will be responsible to pay for the whole program in full.  I understand and I am aware there is a no-refund policy.                               _______ initial

 

I understand in the case of an emergency or a medical problem, Sunshine Center will do their best to reach me.  I give my permission for my emergency contacts and said physicians to make medical decisions that are in the best interest of the said child.  I understand if the representatives of the Sunshine Center are unable to reach me, my family, my physician, or my emergency contacts, I give permission to the medical personnel elected by the program director to follow any procedures necessary for the safety and well being of my child.                                                                                                                                                                      _______ initial

 

I give my child permission to engage in all program activities including games, lunches/snacks, field trips, lessons. I understand that my child MAY be attending a program at the Old Town Equestrian Center which is located across the street and will be under full supervision at all times (Only specified weeks). I understand that the children may walk to Boyle Road School next door to the Center to engage in large group recreation activities. They will be supervised by staff members at all times.                                                      ________ initial

 

I understand my child MAY be participating in pre & post tests and evaluations to monitor the success and effectiveness of this program.  (Specific child’s name/participation is confidential)  ________ initial

 

I understand that any group or program my child attends is not considered therapy or treatment.  While I expect benefits from this program, I fully understand that no particular outcome can be guaranteed.  I understand I am free to take my child out of the program, but that it would be in the best interest of all to talk with the facilitators and directors first.     _______ initial

 

I understand that there may be photographs taken or stories done on the Center.  Photographs are taken for promotional purposes.  Stories are done periodically on the Center and the valuable services it offers through radio, TV, and press.  If the center is represented in the media, it is recognized as a prevention center, providing youth with a safe environment, positive role models, and alternative activities to alcohol, drugs, and violence.  Grants and funding are provided for economically disadvantaged families or children at-risk.  Sometimes this information is recognized in the media reports.  Please make the center aware if you do not want your child involved in any photographs or media reports.                                                                                                  ________  initial  

 

I understand there are basic rules and guidelines that my child must follow.  I agree to review the basic rules and guidelines with my child.  I understand these rules and guidelines will be reviewed with my child during the program.  I understand that if for some reason this program or group is not suitable for my child or the other participants, Sunshine Center will follow the necessary steps as explained in the rules and guidelines.                                                                                                                     ________ initial

                                        

Where as, The Sunshine Center, Inc., also know as Sunshine Prevention Center for Youth & Families, with its principal place of business located at 468 Boyle Road, Port Jefferson Station, NY 11776, will operate a summer program on the said premises, which is owned by the Town of Brookhaven but leased to Sunshine Center, Inc.

Whereas, the undersigned parent/guardian has enrolled (child’s name)________________________  Residing at  (address) __________________________________________________ to participate in the said program and to take part in the activities offered during the Summer  Programs by Sunshine Center, Inc. 

This agreement is in effect from June 30, 2012 through September 1, 2012. 

 

Signed _____________________________________ Print name__________________________________  Date ________________

 

Parent/Guardian of (child’s name)________________________________________________________________________________

*** YOU MUST PAY IN FULL ONE MONTH PRIOR TO THE START OF THE PROGRAM! ***

 

Medical Information           

Immunization Records are required for ALL participants*

 

 

Has your child had a history of any illnesses?  Explain__________________________________

 

Is your child currently taking medicine? _____ Type/For what_____________________________

 

Does your child have any allergies (food, medicine, etc.)? _____ Explain_____________________

 

Does your child have any special dietary needs? _____  Explain ____________________________

You must provide your own lunch – We may provide some snacks for the children

 

 

Child’s Doctor ______________________  Phone Number ________________

 

Child’s Dentist ___________________________  Phone Number ___________________________

 

Text Box: Rules & Guidelines for all participants

Parent/guardian please read rules and sign form. Review rules at home with your child. 
We will review rules daily with participants. Your child must be…

Capable of following the basic rules & guidelines of the center
Capable of staying in the workshops & groups for the designated time
Able to have respect for themselves and others
Able to not harm themselves or others in the group

As a parent/guardian I do understand that any group or program my child attends is not considered therapy or treatment.  While I expect benefits from this program, I fully understand that no particular outcome can be guaranteed.  I understand I am free to take my child out of the program, but that it would be in the best interest of all to talk with the facilitators and directors first.  I understand in this situation I am not entitled to a refund.  

I understand that if for some reason this program or group is not suitable for my child or the other participants, Sunshine Center will take the following steps:
Work with the parent/guardian on resolving these matters 
Meet with Supervisor and parent/guardian
Provide parent/guardian with resources and referrals that can offer and provide my child with the services needed

Sunshine’s Child Assessment Form – Summer 2015

Filling out this form is optional.  The information on this form will help Sunshine to understand your child’s needs and assist us in the development and delivery of successful prevention programs.  All information on this form will be kept completely confidential and will only be accessible to the appropriate staff.

 

Child’s Name _________________________  Age______ Grade in September__________  DOB_________________

 

Your relation to child:    Biological parent _____  Step parent _____  Grandparent _____  Adoptive parent  _____                                  Foster parent _____    Relative _____  Other  _____ (explain)______________

 

What attracted you to this program?___________________________________________________________________

 

What are you hoping for your child to get out of this program?______________________________________________

________________________________________________________________________________________________

 

Family Makeup (Who lives within your household, such as two parents, siblings, etc)______________________________________

 

Please list any family factors that may be affecting your child (e.g. divorce, trauma, abuse, loss) __________________

________________________________________________________________________________________________

Please list any illness, disability, or diagnosis (physical, developmental, mental) that you want to make us aware of ________________________________________________________________________________________________

 

Please list any behavior challenges or situations you want to make us aware of (Anxiety, aggressive behaviors, etc) ________________________________________________________________________________________________

 

How does your child relate in social situations?_________________________________________________

 

How does your child express feelings/anger?_______________________________________________________________________

 

Please describe the best things about your child _____________________________________________________________________

 

Please list any specific concerns you have with your child ________________________________________________

________________________________________________________________________________________________

 

Rate your child’s self esteem           Low ________  Average _________   High________

 

Has your child had any academic or other problems in school? ______  Please explain __________________

________________________________________________________________________________________________

 

Does your child tend to act like a bully? If yes, explain ________________________________________________

________________________________________________________________________________________________

 

Has your child been teased?   Mildly ______         Some _______       Extreme ________

 

Sunshine Center offers a family-centered approach to prevention.  Programs are most effective when the whole family works together to enhance skills.

 

Are you willing to participate in a “Parenting Component” for this program?

Yes __________   No ___________      No cost to parent/guardian

(Enhancing parenting skills and reinforcing skills the children are learning this summer)

 

Best days and times you are available _________________________________________________________

 

Days and times you are NOT available ______________________________________________________

 

Parent Name (Print) ______________________________________________________________________________

 

Signature_________________________________________________________________Date __________________

______ Amount of Deposit you are leaving        _______Check # ______ Cash                 Staff initials _______

_____ Check here if immunization record is attached.

_____ Check here if there is an outside agency responsible for payment (info MUST be complete!)

Name of Agency_____________________________________  Contact Person _______________________

 

 Address___________________________________________________Phone __________________________

You must have the agency contact us for approval before your child’s space is guaranteed.   Please make sure you have this agreement.  Parent/guardian is responsible if the agency fails to pay.

STAFF ONLY-**Payment Info:

 

Staff Only: *** ALLERGY INFO: