Summer 2013 Application Checklist

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Forms Reminder

Camp Application Complete registration form

Payment Form

Checks should be made payable to Camp Nova. We also accept Cash, Visa, Master Card, and American Express. No Refunds.

Authorization for Medication /Treatment

Must be signed by both parents and physician. For all campers.

Non University School Students: Extra Medical Forms

Non University School Students must submit the following two forms: DH/HRS 3040 form and a DH/HRS 680 form which can be requested from your child’s physician.

Visit Camp Nova: Parent FAQs http://uschool.nova.edu/summer/index.html

Camp Nova Orientation

Date: June 8th , 2013 Time: 10am-12pm Location: Epstein Center

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3375 SW 75 Avenue • University Lower School Building • Fort Lauderdale, Florida 33314-1400 (954) 262-4528 • (954) 262-4521 • Fax: (954) 262-3224 • http://uschool.nova.edu/summer/campnova.html

Nova Southeastern University admits students of any race, color, and national or ethnic origin. University School of Nova Southeastern University is accredited by the Southern Association of Colleges and Schools by the

Florida Council of Independent Schools, by the Florida Kindergarten Council, and by the Association of Independent Schools of Florida. University School is a member of the National Association of Independent Schools.

Camp Nova 2013

PARENT/GUARDIAN CONTACT INFORMATION

AUTHORIZATION TO RELEASE:

Other than parent(s), please list additional people who are authorized to pick up the camper.

EMERGENCY CONTACTS

RELEASE OF LIABILITY: As a parent or legal guardian of the above camper(s), I/we agree for the noted camper(s) to attend Camp

Nova: Summer Camp and all off-campus activities. I/we give permission for camper(s) to engage in all prescribed activities as noted. I/we authorize and give consent to any licensed health professional to perform upon or administer to camper(s) any reasonable, necessary medical treatment. Initial: _______

I/we authorize the use of my camper(s) photograph(s) in camp publications, web sites, and or/or advertisements. I/we hereby release Nova Southeastern University, Inc., its trustees, officers, agents, and employees, the University School, its officers, employees, agents and instructors from any and all liability for any injury, damage, claim, demand, action, loss, liability, cost and expense (including, without limitation, reasonable attorney’s fees) of any nature that I/we may at any time have or incur, while taking part in a University School/Camp Nova program. NON-REFUND POLICY: A NON REFUNDABLE DEPOSIT OF $100 PER CHILD/PER SESSION IS REQUIRED FOR YOUR CAMPER TO BE REGISTERED. THIS WILL BE DEDUCTED FROM THE TUITION FOR EACH SESSION. Initial: ______

I understand the deposit enclosed will be applied toward one session of each camper’s basic fee. I agree to pay the balance on or before

April 5, 2013. I am aware this deposit is non-refundable and will be forfeited if my child does not attend Camp Nova. There is no-refund for

late arrival or early departure for a camper dismissed for disciplinary action or for emergency weather situations. If payment procedures are not followed, the person responsible for payment will be sent to collections.

Refunds are not issued if a child is dismissed due to disciplinary action based on his/her behavior or misconduct. Only in the case of an extreme medical emergency will this policy be reviewed by University School. Refunds will also not be issued in the event that the National Hurricane Center broadcasts a “hurricane/tropical storm warning” for our area. In such a case, Camp Nova will cancel its program for the duration of the inclement weather. We reserve the right to cancel programs if there is insufficient enrollment.

Parent/Guardian Signature: ____________________________________________________ Date: _____________________ Name: __________________________ Relationship: ________________________ Phone 1: ______________ Phone 2: ___________ Name: __________________________ Relationship: ________________________ Phone 1: ______________ Phone 2: ___________ Name: __________________________ Relationship: ________________________ Phone 1: ______________ Phone 2: ___________ Name: __________________________ Relationship: ________________________ Phone 1: ______________ Phone 2: ___________ Name: __________________________ Relationship: ________________________ Phone 1: ______________ Phone 2: ___________

Camper 1: Name: ___________________________M___ F___ D.O.B: ______________ Grade Entering in the fall: _________ School: _____________________________________________

Camper 2: Name: ___________________________M___ F___ D.O.B: ______________ Grade Entering in the fall: _________ School: _____________________________________________

Mother/Guardian/Co-Parent

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SESSION 2: 6/24/13-7/5/13

Arts and Crafts General Sports Karate Kids Robotics Archery Science of Cooking Dance Digital Photography SESSION 3: 7/8/13-7/19/13

Arts and Crafts General Sports Karate Kids Robotics Archery Science of Cooking Dance Digital Photography Jr. Camp Nova (K-1st Grade Only)

Teen Travel Camp (8th-10th Grade Only)

C.I.T. (9th-12th Grade Only)

Cheer Camp (2nd-8th Grade Only)

Session 1: 6/10/13-6/21/13 Session 1: 6/10/13-6/21/13 Session 1: 6/10/13-6/21/13 Session 1: 6/10/13-6/21/13

Volleyball Camp (2nd-8th Grade Only) Basketball Camp (2nd-6th Grade Only) Jr. Lifeguard (4th-8th Grade Only)

Week 7:7/22/13-7/26/13 Week 1: 6/10/13-6/14/13 Session 2: 6/24/13-7/5/13

Week 2: 6/17/13-6/21/13

SESSION 1: 6/10/13-6/21/13

Arts and Crafts General Sports Karate Kids Robotics Archery Science of Cooking Dance Digital Photography

BEFORE CARE (7:30-8:30 AM) AND/OR AFTERCARE (3:30-5:30 PM)

AM PM AM PM AM PM

RELEASE: THIS STATEMENT MUST BE SIGNED FOR ATTENDANCE. The person herein described has permission to engage in all prescribed activities as noted. Initial: ______________

MEDICAL INFORMATION

Your camper’s health and safety is very important to all of us at Camp Nova. Please be assured that we will share any and all medical/allergy information with your campers’ counselors, including all camp vendors (i.e. Magic Program) who interact with your children. Please let us know if there are any additional concerns that the Camp Nova staff should be aware of? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________

CORE CAMPS (Grades 2-8 Only)

Full Day Camps – Campers will spend each full day participating in the activity as well as participate in swimming, fieldtrips and camp-wide activities.

(One form per camper)

Camper 1: Name__________________________________________________________________________________________

Date of Birth _____________Age__________ Female ____ Male____ Grade in fall _________Shirt Size Child S M L

Adult S M L

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Camp Nova 2013

SESSION 2: 6/24/13-7/5/13

Arts and Crafts General Sports Karate Kids Robotics Archery Science of Cooking Dance Digital Photography Jr. Camp Nova (K-1st Grade Only)

Teen Travel Camp (8th-10th Grade Only)

C.I.T.

(9th-12th Grade Only)

Cheer Camp (2nd-8th Grade Only)

Volleyball Camp (2nd-8th Grade Only) Basketball Camp (2nd-6th Grade Only) Jr. Lifeguard (4th-8th Grade Only)

Week 7:7/22/13-7/26/13 Session 1: 6/10/13-6/14/13 Session 2: 6/24/13-7/5/13

Session 2: 6/17/13-6/21/13

BEFORE CARE (7:30-8:30 AM) AND/OR AFTERCARE (3:30-5:30 PM)

AM PM AM PM AM PM AM PM

RELEASE: THIS STATEMENT MUST BE SIGNED FOR ATTENDANCE. The person herein described has permission to engage in all prescribed activities as noted. Initial: ______________

MEDICAL INFORMATION

Your camper’s health and safety is very important to all of us at Camp Nova. Please be assured that we will share any and all medical/allergy information with your campers’ counselors, including all camp vendors (i.e. Magic Program) who interact

with your children. Please let us know if there are any additional concerns that the Camp Nova staff should be aware of? _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

(One form per camper)

Camper 2: Name__________________________________________________________________________________________

Date of Birth _____________Age__________ Female ____ Male____ Grade in fall _________Shirt Size Child S M L

Adult S M L

SESSION 1: 6/10/13-6/21/13

Arts and Crafts General Sports Karate Kids Robotics Archery Science of Cooking Dance Digital Photography

CORE CAMPS (Grades 2-8 Only)

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Payment Form

DEPOSITS AND PAYMENT

A non-refundable deposit of $100.00 per camper, per session must accompany the application for registration to be complete. This deposit will be applied to the camp fees. The person responsible for payment must sign the application form. Camp Nova has a no-refund policy.

All accounts must be paid in full by May 3th_{, 2013}

Upon receipt of the application, a confirmation will be sent that includes the balance due and the dates by which payment must be received. If you do not receive a confirmation within two weeks of sending in the application, please call the camp office at (954) 262-4528.

Camper 1 Name: __ Camper 2 Name: _

Teen Travel _{2 Weeks 4 Weeks} _{6 Weeks} _{8 Weeks}

Tuition $625.00 $1,200.00 $1,725.00 $2,300.00

Before Care $62.50 $125.00 $187.50 $250.00

After Care $65.00 $130.00 $195.00 $260.00

Before &

After Care $125.00 $250.00 $375.00 $500.00

Teen Travel _{2 Weeks 4 Weeks} _{6 Weeks} _{8 Weeks}

Tuition $625.00 $1,200.00 $1,725.00 $2,300.00

Before Care $62.50 $125.00 $187.50 $250.00

After Care $65.00 $130.00 $195.00 $260.00

Before &

After Care $125.00 $250.00 $375.00 $500.00

Camper 1: 2 Weeks 4 Weeks 6 Weeks 8 Weeks

Camp Nova Tuition $575.00 $1,125.00 $1,610.00 $2,060.00 Before Care $62.50 $125.00 $187.50 $250.00 After Care $65.00 $130.00 $195.00 $260.00 Before & After Care $125.00 $250.00 $375.00 $500.00

Camper 2: 2 Weeks 4 Weeks 6 Weeks 8 Weeks

Camp Nova Tuition $575.00 $1,125.00 $1,610.00 $2,060.00 Before Care $62.50 $125.00 $187.50 $250.00 After Care $65.00 $130.00 $195.00 $260.00 Before & After Care $125.00 $250.00 $375.00 $500.00 BASKETBALL

CAMP Week 1 Week 2

Tuition $200.00 $200.00

Before Care $31.25 $31.25

After Care $32.50 $32.50

Before & After

Care $62.50 $62.50

BASKETBALL

CAMP Week 1 Week 2

Tuition $200.00 $200.00

Before Care $31.25 $31.25

After Care $32.50 $32.50

Before & After Care $62.50 $62.50

CIT Weeks 1-4 Weeks 5-8

Tuition $400.00 $400.00

CIT Weeks 1-4 Weeks 5-8

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Camp Nova 2013

Pay By: Check • Cash • MasterCard • Visa • American Express -ALL DEPOSITS ARE NON-REFUNDABLE-

Make check payable to: Camp Nova

Credit card type: VISA MASTERCARD AMEX

Cardholder’s name: Signature: ______________________

Credit card #: Expiration Date: ________/__________/_______

Billing Address: Amount: $ _________________________________

Billing Zip Code: ___________________

Registration forms can be faxed or submitted to the Camp Office located in the University Lower School

Additional T-shirt order: $15.00 each: __________________ Camp Nova Tote bag: $18.00 each: __________________ Total: $_________________

Additional T-shirt order: $15.00 each: __________________ Camp Nova Tote bag: $18.00 each: __________________ Total: $_________________ Jr. Lifeguard 2 Weeks Tuition $450.00 Before Care $62.50 After Care $65.00

Before & After

Care $125.00

Cheer

Camp: 2 Weeks 4 Weeks 6 Weeks 8 Weeks

Camp Nova Tuition $450.00 $875.00 $1,275.00 $1,650.00 Before Care $62.50 $125.00 $187.50 $250.00 After Care $65.00 $130.00 $195.00 $260.00 Before & After Care $125.00 $250.00 $375.00 $500.00 Cheer

Camp: 2 Weeks 4 Weeks 6 Weeks 8 Weeks

Camp Nova Tuition $450.00 $875.00 $1,275.00 $1,650.00 Before Care $62.50 $125.00 $187.50 $250.00 After Care $65.00 $130.00 $195.00 $260.00 Before & After Care $125.00 $250.00 $375.00 $500.00 Jr. Lifeguard 2 Weeks Tuition $450.00 Before Care $62.50 After Care $65.00

Before & After

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Student Name: Allergies: Date of Birth:

Age: Grade:

OTC (Over-the-counter) STANDING ORDERS

MEDIATION DOSAGE FREQUENCY INDICATION FOR USE

Acetaminophen Ibuprofen Benadryl Tums Caladryl Lotion Neosporin Chloraseptic Spray

OTHER MEDICATIONS

MEDICATION DOSAGE FREQUENCY INDICATION FOR USE

TREATMENTS DURING CAMP HOURS (i.e.; nebulizer, blood glucose checks, etc):

ADDITIONAL FORMS NEEDED!

IMPORTANT: Broward County Dept. of Health requires us to have a physician signed copy of current (within one year of the first day of Summer Programs) Certificate of Good health, known as the DH/HRS 3040 (YELLOW) AND DH/HRS 680 (BLUE) FORMS. ALL NON UNIVERSITY SCHOOL STUDENTS MUST SUBMIT ORIGINAL COPIES OF THE BLUE AND YELLOW FORMS IN ADDITION TO THIS AUTHORIZATION FOR MEDICATION/TREATMENT FORM. A sample of the blue and yellow sheets can be found in this packet.

____________________________ ________________________________________________________ ____/___/____ Physician’s Name (Please print) Physician’s Signature and Stamp Date

Physician’s Phone: ( ) Physician’s Fax: ( )

I grant the nurse, and/or primary designee the permission to assist or perform the administration of each medication or

treatment/procedure to/for my child during Summer Programs including when he/she is away from the property on scheduled field trips.

This form MUST BE SIGNED BY THE CAMPER’S PARENT/GUARDIAN AND PHYSICIAN. No student will be permitted to

participate in University School’s Summer Programs without returning this form with BOTH signatures. The purpose of this form is to allow University School’s nurse and directed staff to carry out minor medical treatment (such as band-aids) when needed. Even if you do not want the program to administer any type of aid to your camper this form must be turned in.

 If physician’s signature is not present we CANNOT give out any authorized medication to camper if needed!

 Any medication sent from home, including OTC and prescription, must be in the original container.

 Only medications/treatments authorized by a physician may be administered by Summer Program personnel.

Summer 2013 Application Checklist

Payment Form

Camper 1 Name: ________________________________ Camper 2 Name: _______________________________

OTC (Over-the-counter) STANDING ORDERS

OTHER MEDICATIONS

ADDITIONAL FORMS NEEDED!

Camper 1 Name: __ Camper 2 Name: _