Welcome to Junior Camp/Quad!

1. Referral Credit: Refer a new family and receive a $50 credit when they enroll. The referring family’s name

must be listed on the new family's registration form.

2. There will be a fee assessed for incomplete forms requiring multiple audits. Registration Form

• Include street addresses and ZIP codes for all parents, contacts and medical facilities. • Include full phone numbers, not just Quad extensions.

• Specify either " □ no medical condition" or indicate which medical conditions your child has, as well as medical instructions to staff. This is on page 2.

• Don't forget to sign and date on all four lines.

• Policies are included so everyone has access to any policy updates. Payroll Authorization/Payment Agreement

• This form is required by all families.

• If you already have a payment plan in place, this form will help us to determine if the current plan is sufficient. Please do not assume we know your deduction amounts. If we must look them up, it is a different part of the audit. Page 2 of this form is a worksheet to help you determine the amount of your weekly payment.

• If you are using an alternate form of payment, please discuss this with us in advance. You can then mark "No deduction - other" and indicate terms of agreement.

• Don't forget to sign and date. Prospective Attendance Form

• Mark each day of the calendar section with an "X" or a "√ ". This will indicate the first and last day of your child's attendance.

• Please also be sure to look over the rest of the form and mark any other boxes necessary. • Other areas to mark are the drop off and pick up times, sleepover attendance and movie

considerations.

• There are two pages to this form. • Don't forget to sign and date. Immunization Form

• New campers will need to complete an immunization form even if your child attended the QuadCare center last year. A printout from your child's medical facility listing the immunizations may be attached to the form. • Returning campers do not need to have all immunizations listed, as long as your child did not receive

additional vaccinations since last summer. You can indicate this by marking steps 1 and 5. • Don't forget to sign and date.

www.QUAD.com/quadcare * 414.566.2170

Welcome to Junior

Camp/Quad!

Please take note of the follo

w

ing guidelines to help

y

ou through

Child ID

Jr. Camp/Quad Summer Registration, Health History & Emergency Care Plan

$75.00 first school age child registration fee ~ $10.00 per each additional school age child. Please fill out a separate form for each child. $25.00 handling fee for multiple audits.

All information on these forms is required by state of WI DCF Codes. Parents are required to inform us in writing of any changes to this information.

Date (MM-DD-YY) CHILD

INFORMATION How did you hear about us? □ Friend/Relative - List name for referral credit _{□ Newspaper Ad □ Newspaper Article □ Marquee □ Flyer □ Other}

Name (Last, First, Middle) Home Address (Street, City, State, Zip Code) Gender

□

Male

□

Female Nickname Birth Date (mm/dd/yyyy) _{Family Status:}

_□

_Married

_□

_Divorced

_□

_Single

□

Widowed

□

Guardian

□

Other

PARENT / GUARDIAN INFORMATION provide all information regarding how the parent can be reached while the child is in care.

Name:

Relationship to child: □ Parent □ Legal Guardian Employer:

Employer’s Street Address: City/State/Zip Code: Email Address:

Telephone Number – Work Employee ID (if Q/G employee)

Telephone Number

□ Cell □ Home

Name: Telephone Number – Work Telephone Number

Relationship to child: □ Parent □ Legal Guardian

Employer: □ Cell

Employer’s Street Address: Employee ID (if Q/G employee)

City/State/Zip Code: □ Home

Email address:

EMERGENCY CONTACT / AUTHORIZED ESCORT INFORMATION: EMERGENCY CONTACT ~ Someone that can help us find the parent quickly in an emergency. AUTHORIZED ESCORT ~ Someone with permission to pick up your child.

Name:

Relationship to child:

□ Authorized Escort □ Emergency Contact

Employer: Street Address: City/State/Zip Code:

Telephone Number – Work Employee ID (if Q/G employee)

Telephone Number

□ Cell □ Home

Name: Telephone Number – Work Telephone Number

Relationship to child:

□ Authorized Escort □ Emergency Contact □ Cell

Employer: Employee ID (if Q/G employee)

Street Address: □ Home

City/State/Zip Code:

DENTAL & PHYSICIAN / MEDICAL FACILITY INFORMATION

Name – Medical Facility & Primary Physician Address - (Street/City/State/Zip) Telephone Number Name – Medical Facility & Primary Dentist Address - (Street/City/State/Zip) Telephone Number

ANTI-ITCH CREAM, SUNSCREEN / INSECT REPELLENT AUTHORIZATION ~ Jr. Camp/Quad uses Dr. Scheffields Anti-Itch Cream, NoAd, Equate,

Up&Up Up&Up &/or Walgreens 30+ SPF Sunscreen & Off Brand Repellent with 25% or less Deet. I understand Jr. Camp/Quad will use and apply this cream, sunscreen/repellent to my child unless noted below.

FIELD TRIP AUTHORIZATION:

□ Yes □ No ~ I give permission for my child to participate and be transported for fieldtrips/activities

Whom shall apply my child’s:

Bug Repellent: Sun Screen: Anti-Itch Cream:

□

Quad Staff

□

My child

□

Staff & My Child

□

My child has a repellent allergy & will not use bug repellent

□

I will supply the following repellent for my child: List Brand Name & Active Ingredient Strength:

□

Quad Staff

□

My child

□

Staff & My Child

□

My child has a sunscreen allergy & will not use sunscreen

□

I will supply the following sunscreen for my child.

List Brand Name & SPF Strength:

□

Quad Staff

□

My child

□

Staff & My Child

□

I will supply the following anti-itch cream for my child List Brand Name:

Please sign each statement below - failure for parents to sign may result in termination of enrollment

REGISTRATION, HEALTH HISTORY & EMERGENCY CARE PLAN (page 2) for (name & ID)

MEDICAL CONDITIONS - Check any special medical condition that your child may have. If available, attach any health care plan information from the child’s

physician, therapists, etc.

□ No specific medical condition □ Cerebral Palsy / Motor Disorder

□ Asthma □ Diabetes □ Epilepsy / Seizure Disorder □ Gastrointestinal or feeding concerns including special diet and supplements □ Any disorder including Cognitive Disabilities (LD, ADD, ODD, ADHD, Autism / Autism Spectrum etc) - Please specify:

□ Other condition(s) requiring special care – Specify: Allergies

□ Milk Allergy/Sensitivity (please list plan for substitution/alternative): □ Food Allergies – Specify foods / beverages:

□ Non-food allergies – Specify: Medical Instructions

1. Triggers that may cause problems: 2. Signs & symptoms to watch for:

3. Steps the child care provider should follow:

4. When to call parents regarding symptoms or failure to respond to treatment:

5. When to consider that the condition requires emergency medical care or reassessment: 6. Additional information that may be helpful to the child care provider:

Deductions: (Quad employees) Tuition will be deducted by payroll in one of two ways, or through a combination of both:

 Using Pre-Tax Dollars: Pre-Tax Dollars will be deducted from the weekly paycheck and applied toward tuition. If you choose this method of payment you must

sign up for this program in November of each year (during Open Enrollment) or if a change in family status has taken place. Forms are available in Employee Services or by contacting MyQuad (1.866.275.3737 or [email protected]).

 Regular Payroll deduction: After Tax Dollars will be deducted from the weekly paycheck and applied to tuition. The dollar amount specified can be changed

throughout the year. A Form may be obtained in your Child-Care Center office, Employee Services or by contacting MyQuad.

Payments: Community parents are required to have tuition payments paid prior to services.

You will be billed & payment is expected on a biweekly basis. Employees may be required to pay in full and collect familial payment from responsible parties. Checks may be mailed or deposited in the drop box located in the Q/Care office. I understand my bill must remain current in order for my child to continue attending camp.

Billing Signature – Parent/Guardian: ________________________________________________________ Date:

I give permission for my child to attend field trips, be photographed on field trips and in the classroom and I understand the photographs may be used for advertising purposes.

Fieldtrip Signature – Parent/Guardian: _______________________________________________________ Date:

I have received a copy of the Jr. Camp guidelines, tuition schedule & payment guidelines and agree to abide by all Quad/Care policies. I understand these guidelines & policies are also available on request, online & a copy of “Wisconsin Rules for Licensing Camps” is available to me for review.

Guidelines Signature – Parent/Guardian: _____________________________________________________ Date:

If there should happen to be a medical emergency concerning my child’s well-being as the result of illness or an accident, I give my permission to have my child transported and treated at the nearest medical facility for emergency medical treatment. I understand that I will be financially responsible for expenses not covered by my insurance provider.

Medical Signature – Parent/Guardian: ________________________________________________________ Date:

 

085

QuadCare Summer Camp Payroll Authorization/Payment Plan 

Parent/Guardian Name: ________________________________________________________  Community Families:  Paying Average Weekly Tuition of $ __________ in Advance    Other ___________________________  Quad/Graphics Employee Families:  Quad/Graphics cannot deduct a fluctuating balance. Please use the worksheet on the back to determine your weekly  average deduction. I authorize Quad/Graphics to deduct $ __________ from my weekly payroll check.  This amount will  be applied directly to my QuadCare balance.  Any QuadCare balance not covered by this deduction remains my  responsibility and should be paid on a regular weekly schedule.  Deductions are to start with the payroll effective:   New Deduction Setup   After Tax Deduction already in place – Current Weekly Deduction $_______  Pre Tax Dependent Care Flex already in place – Dependent Care Flex amount $_______  No Deduction: Other _________________________________  Deduction Change (After‐Tax Only) 

Increasing Deduction Amount    Decreasing Deduction Amount   Stopping Deduction  Reason for Change:  ________________________________________________________________________________         ________________________________________________________________________________  Community & Quad/Graphics Employee Families:  1) _________________________________________ _________________  2) _________________________________________ _________________  3) _________________________________________ _________________  Parent/Guardian Signature: ___________________________________________________          To complete enrollment process please submit to QuadCare Office  For Office Use Only  Office Notes:  ______________________________________  QuadCare Approval:  ___________     Date:  ______________  Accounting Approval:  __________     Date:  ______________ 

*085A*

Date MM‐DD‐YY (Required)  (please print)  Child(ren) Name:  Estimated # of days of attendance  between June and Sept.  If Quad Employee ‐ ID Required 2/13/2017  Child ID # Child ID # Child ID # Date MM‐DD‐YY (Required) 

Payroll Deduction Worksheet 

School Age Child’s Name  # days attending  all summer  Cost per day  Total Cost   of Trips  Summer Total 

x 

$ 

+ 

$ 

= 

$ 

x 

$ 

+ 

$ 

= 

$ 

x 

$ 

+ 

$ 

= 

$  Add totals and divide by 12 (the number of weeks in the program) to get your total weekly  payroll deduction. Add this amount to your current deduction if you already have children  attending the center.  $  * Please contact us if you have questions.

Quad/Graphics Employees 

Community Families 

Full Day (up to 10 fixed hours) 

2

nd

 _{child discount} 

$41.10 

Full Day (up to 10 fixed hours) 

2

nd

 _{child discount} 

$54.90 

$37.00 

$49.40 

Extended Day (over 10 hours) 

2

nd

 _{child discount} 

$48.80 

Extended Day (over hours) 

2

nd

 _{child discount} 

$62.60 

$43.90 

$56.35 

* Please see program brochure for fieldtrip costs

Quad/Graphics Addresses 

Sussex Plant / Corporate Headquarters

N61 W23044 Harry’s Way Sussex, WI 53089

Pewaukee Plant

W224 N3322 Duplainville Rd. Pewaukee, WI 53072

Midwest Commingling Center

W228 N2801 Duplainville Rd. Waukesha, WI 53816

Hartford Plant

1900 West Sumner Street Hartford, WI 53027

West Allis Plant / West Allis Quad/Med

555 South 108th _St.

West Allis, WI 53214 Pediatrics 414-566-8200

Sussex Quad/Med Clinic

W227 N6103 Sussex Rd. Sussex, WI 53089 Pediatrics 414-566-8000

Quad/Med Corp. Circle

N53 W24700 Corporate Cir. Sussex, WI 53089

Lomira Plant / Lomira Quad/Med

N11896 Highway 175 Lomira, WI 53048 Pediatrics 414-566-8310

Hartford Quad/Med (Froedtert Offsite)

110 Lone Oak Lane Hartford, WI 53027 262-670-1800

1

Prospective Attendance, Field Trip & Movie Authorization

Child’s Name _____________________________________________________

Please X or



each day your child will (or might) attend camp this summer. Please note that pre and post weeks are reserved for families enrolled on a regular basis. Due to limited staffing, we are unable to enroll children just for these weeks. Staff, meals, bus contracts and supplies will be arranged according

to the number of children scheduled for each day. We will ask you to confirm this schedule 2 weeks in

advance. Your schedule is negotiable until 2 weeks prior, at which time it becomes locked for staffing and

planning. Please make note if and how the Quad production rotations affect your child’s attendance schedule.

Camp opens on June 14th_{, 2021. Care needed prior to June 14}th _{can be arranged through the camp}

director. Please be sure to include these days on the calendar below as part of your regular enrollment.

Pre Week & Post Weeks as Critical Scheduling: Shaded areas denote limited staff availability.

Scheduling accuracy is critical at these times & space may not be available for late requests. Again, pre weeks and post weeks are also limited to families enrolled on a regular basis. We will ask for confirmations as these days draw closer.

Pre Week & Post Weeks: Children scheduled for care during these weeks must also be regularly scheduled throughout the summer.

My child will / might attend the Sleepover/Fundraiser Event from Friday July 30th _{5:30 p.m. through Saturday July 31}st _{8:30 a.m.}

JUNE JULY AUGUST

M T W R F M T W R F M T W R F 1 2 3 4 1 2 2 3 4 5 6 7 8 9 10 11 5 6 7 8 9 9 10 11 12 13 14 15 16 17 18 12 13 14 15 16 16 17 18 19 20 21 22 23 24 25 19 20 21 22 23 23 24 25 26 27 28 29 30 26 27 28 29 30 30 31 9/1 9/2 9/3

Please mark each day your child will attend.

Please mark the approximate times you will be dropping off and picking up your child daily. Drop Off (Start Time) _______________ Pick Up (End Time)_________________

2 Field Trip/Activity Expectations:

We are planning to attend some trips this summer if we can assure that high standards of hygiene and sanitation practice are followed by the preferred vendors. Field trips and special activities are a privilege. Field trips will be announced well in advance.

All children participating in school-age field trips and activities are expected to:

 Be on time to fully prepare for trip ~ pack a lunch, change, attend group meeting. We ask that children arrive no later than 8:00 on trip days. You may call ahead with a sandwich order to save time.

(414.587.4365)

 Be prepared and dressed appropriately  Listen to and follow directions

 Control their behavior

 Treat teachers, peers and property in a respectful manner  Be respectful of practices guiding use of the premise

 Display appropriate behavior and use appropriate language. Inappropriate physical behavior, language (including the use of threats, profanity, or discussing inappropriate content), poor attitude and

disrespecting people and property, whether on a trip or at base camp, will result in a phone call to the parent and possible exclusion from future trips, activities or camp. See discipline insert for more details.

Possible causes for exclusion:

 Child requires one-to-one care – Jr. Camp/Quad staff to child ratios do not allow for one-to-one care.  Failure to meet expectations listed above may result in exclusion from field trips/activities or the child’s

parent may be required to chaperone in order for the child to attend. Consequences are determined after reviewing the situation, the child’s age and development, and the severity or frequency of the behavior as well as the child’s overall behavior.

 Failure to improve behavior or inappropriate behavior occurring on a regular basis may also result in termination of care.

Movies: Due to the variety of child interest, ages and development, I understand children may view movies

rated PG.

Please check one:

 I do not have viewing concerns

 I have viewing concerns and will discuss them with my child’s counselors. Field trip attendance:

 My child(ren) may attend any fieldtrips and activities on the days they are scheduled to attend Junior Camp/Quad. In the event I do not want my child to attend a specific trip, I will make alternate

arrangements for my child. I understand that failure to meet expectations may result in my child’s possible exclusion from trips or activities. Staff will not stay back to provide one on one care.

Child’s Name & Age ____________________________________________________________________ Parent’s Signature & Date ________________________________________________________________

DEPARTMENT OF HEALTH SERVICES

Division of Public Health F-44192 (Rev. 09/08) JR. CAMP/QUAD IMMUNIZATION RECORD STATE OF WISCONSIN ss. 252.04,Wis. Stats.

COMPLETE AND RETURN TO DAY CARE/CAMP CENTER . State law requires all children in day care centers to present evidence of immunization

against certain diseases within 30 school days (6 calendar weeks) of admission to the day care center. These requirements can be waived only if a properly signed health, religious, or personal conviction waiver is filed with the day care center. See “Waivers” below. If you have any questions on immunizations or how to complete this form, please contact your child’s day care provider or your local health department.

PERSONAL DATA PLEASE PRINT

Step 1 Child’s Name (Last, First, Middle) Date of Birth (month/day/year) Area Code/Phone Number Parent/Guardian/Legal Custodian (last, First, Middle Initial) Address (Street, Apartment Number, City, State, Zip)

Step 2 IMMUNIZATION HISTORY List the MONTH, DAY AND YEAR the child received each of the following immunizations. DO NOT USE A (4) OR (X) except to indicate whether the child has had chickenpox. If you do not have an immunization record for this child, contact your doctor or local public health department to obtain the records.

TYPE OF VACCINE First Dose

mm/dd/yyyy Second Dose mm/dd/yyyy mm/dd/yyyy Third Dose Fourth Dose mm/dd/yyyy mm/dd/yyyy Fifth Dose Diphtheria-Tetanus-Pertussis

(Specify DTP,DTaP or DT) Polio

Hib (Haemophilius Influenza Type B)

Pneumococcal Conjugate Vaccine (PCV) Hepatitis B

Measles-Mumps-Rubella (MMR) Varicella (chickenpox) vaccine

Vaccine is required ONLY if the child has NOT had the chickenpox disease

Has your child had the Varicella ( chickenpox ) disease? Check the appropriate box & provide the year if known.

□YES __________year (Vaccine is not required) □NO or UNSURE (Vaccine is required)

Step 3 REQUIREMENTS The following are the minimum required immunizations for the child’s age/grade at entry. All children within the range must meet these requirements at daycare/camp entrance. Children who reach a new age/grade level while attending care must have their records updated with dates of additional required doses.

AGE LEVELS NUMBER OF DOSES

DTP/DTaP/DT Polio Hib PCV Hep B MMR Varicella

5 months through 15 months 2 2 2 2 2

16 months through 23 months 3 2 31 ₃2 _{2 1}3

2 years through 4 years 4 3 31 32 3 13 1

At kindergarten entrance (PCV) ₄4 _{4 3 2}3 ₂

1

If the child began the Hib series at 12-14 months of age, only 2 doses are required. If the child received one dose of Hib at 15 months of age or after, no additional doses are required. Minimum of one dose must be received after 12 months of age. (Note: a dose 4 days or less before the first birthday is also acceptable)

2 _{If the child began the PCV series at 12-23 months of age, only 2 doses are required. If the child received the first dose of PCV at 24 months}

of age or after, no additional doses are required.

3

MMR vaccine must have been received on or after the first birthday (Note: a dose 4 days or less before the first birthday is also acceptable).

4

Children entering kindergarten must have received one dose after the 4th _{birthday (either the 3}rd_{, 4}th _{or 5}th_{) to be compliant (Note: a dose 4}

days or less before the first birthday is also acceptable).

Step 4 COMPLIANCE DATA AND WAIVERS - IF THE CHILD MEETS ALL REQUIREMENTS (sign at step 5) OR IF THE CHILD DOES NOT

MEET ALL REQUIREMENTS (check the appropriate box)

□

Although the child has not received all required doses of vaccine for his/her age group, at least the first dose of each vaccine has been received. I understand that it is my responsibility to obtain the remaining required doses of vaccine for this child WITHIN ONE YEAR and to notify the daycare/camp in writing as each dose is received.

NOTE: Failure to stay on schedule or report immunizations to the daycare/camp may result in court action against the parents and up to a fine of $25.00 per day of violation.

□

For health reasons this child should not receive the following immunizations_________ (List in Step 2 any immunizations already received) _______________________________________________________________________________ Physicians Signature Required Date Signed

□

For religious reasons this child should not be immunized (List in Step 2 any immunizations already received)

□

For personal conviction reasonsthis child should not be immunized (List in Step 2 any immunizations already received) Step 5 _{SIGNATURE □ To the best of my knowledge this form is complete and accurate.}

□

At this time there are no updates to last year’s immunization records.

Parent/Guardian/Legal Custodian Date

*05*