Diener Camp 2024 Registration Form Step 1 of 3 33% Camper DetailsName of Camper(Required) First Last Date of Birth(Required) Age(Required) Camp T-Shirt Size(Required) Parent/Guardian #1(Required) First Last Email Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Cell Phone(Required)Home PhoneWork PhoneParent / Guardian #2 First Last Address if Different Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Cell Phone(Required)Home PhoneWork PhoneEmergency Contact InformationIn the event parents/guardians cannot be reached.Emergency Contact #1(Required) First Last Emergency Contact #1 Phone(Required)Emergency Contact #2(Required) First Last Emergency Contact #2 Phone(Required)Primary Care Physician(Required) First Last Primary Care Phone(Required) Health InformationAre there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware?(Required) No Yes Health problems Explain.Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child’s camp experience is positive?(Required) No Yes Explain.Immunization InformationFor campers who currently reside within the United States, a United States territory, or the District of Columbia: Does the camper have any immunization exemptions because of a parental or guardian objection or medical contraindication?(Required) No Yes ListFor campers who reside outside the United States, a United States territory, or the District of Columbia: Attach record of vaccination or immunity on Department form MDH-896. Drop files here or Select files Accepted file types: jpg, pdf, doc, Max. file size: 500 MB. Important RemindersCamp hours: Monday through Thursday: 9:00am - 3:00pm Friday: 9:00am - 1:00pm All drop-offs and pick-ups are at The Diener School.Permissions/WaiversConsent(Required) I/We agree to the Diener Camp policy.1. I authorize and permit my child to participate in all Diener-sponsored activities including in school field trips and activities off campus of Diener School. I understand that off-campus activities will be under the supervision of a Diener School employee. 2. I consent to having my child transported in the vehicle of an employee or other chaperone if necessary, for medical, disciplinary or other reasons, in the judgment of the supervising employee. 3. I understand my child will be supervised by Diener personnel and is expected to follow all Diener rules and instructions at all times. 4. I agree that my child will not bring hand-held games, ipods, or other electronics or valuables to camp. I understand that Diener is not responsible for any personal items lost, stolen or damaged at its programs. 5. I give Diener permission to photograph/video my child and use photos/videos in connection with promoting camp programs. 6. I also authorize any medical treatment in case of an emergency and agree that I am responsible for the cost of such treatment. I agree to hold the School and all other persons acting in its behalf or on behalf of field trip sites harmless and release them from any loss, injury, damage, costs and liability of every nature, kind and description arising from such field trips and from any medical treatment and which are not the result of gross negligence by the School, field site, or any persons acting on their behalf. Further, I/we expressly authorize School staff and volunteers participating in such field trips to review my/our child’s medical records prior to any field trip and disclose, without limitation, information from such medical records to medical providers in the event of an emergency. 7. Assumption of Risk and Indemnity: I assume responsibility for all injuries, loss or damage to property, harms, and/or death, that my/our child may suffer as a result of participation in Diener-sponsored activities. I, on behalf of myself and on behalf of my minor child and to the fullest extent permitted by law, agree to hold the Diener School, the field sites, and all other persons acting on their behalf harmless and release them from any loss, injury, damage, costs and liability of every nature, kind and description arising from any activity, program, or event on the Diener campus, or during any activity, program, or event off the Diener campus under the supervision of the Diener School and which are not the result of gross negligence by the Diener School, the filed sites, or any persons acting on their behalf. I and the Student also hereby agree to indemnify and hold the School harmless for any damages incurred by the School or any third party as a result of actions taken by the Student or his/her parents or legal guardians. COVID-19 Notice & Disclosure Although the School will meet all applicable safety requirements, so long as COVID-19 continues to spread by community transmission and until there is an effective vaccine available, there will be a risk that students could become infected with COVID-19 despite the School’s efforts. That risk extends to the families of students, as well as others with whom the student may have contact. By signing this Contract, I acknowledge and agree, on my own behalf and on behalf of the Student, that despite the School’s efforts to operate safely, there is nonetheless a risk that the Student could contract COVID-19 and/or become a symptomatic and/or asymptomatic carrier of COVID-19, and/or develop MIS-C. Financial Policies 1. Payment in full is due by June 3, 2024. After that date, your registration may be released to another camper. 2. The application fee is non-refundable. 3. Cancellations and Non-Attendance: Due to commitments to staff and materials prior to the start of the season, no refunds will be made in connection with late cancellations, late arrivals, early withdrawals, vacations, or camp dismissals due to misconduct. There will be no reduction or refund of fees for the discontinuation of the camp season due to illness, injury, acts of God, natural disasters, acts of war, terrorism, fire, pandemics, or epidemics. Missed days are not refunded or transferred (e.g., missed Friday and want to come back next week for a day). Diener reserves the right to apply any credit due to other outstanding balances. 4. Diener makes every effort to ensure the good-faith operation of its programs, however all camp trips and activities as detailed in camp descriptions are subject to change. Diener reserves the right to make changes in personnel to any program without prior notice. Times, Drop-Off, and Pick-Up 1. Drop-Off is at The Diener School between 9:00am – 9:10am. There will be a Diener staff member at the traffic circle to assist your child and help them get to their room. 2. Pick-Up is at The Diener School 3:00 pm Monday – Thursday and 1:00pm Friday. Please arrive on time to pick up your child. Camp staff will escort your child to your car. When waiting for your child, please DO NOT LEAVE YOUR CAR and please do not linger in the parking lot after your child has been placed in your car. 3. Early Drop Off/Pick-Up: If you are dropping your child off late in the morning or picking them up early from Diener Camp, please come to the main office to sign in/out and a Diener staff member will assist the camper to their room/main office. 4. Weather Closings: Weather decisions will be communicated via email, and phone. Parents are responsible for picking up their children as quickly as possible after an unexpected early dismissal. In the event a parent cannot reach the school to pick up his/her student, the parent needs to call the school to make alternative arrangements for the student to get home. In case of an active thunderstorm during dismissal, the school’s policy is to keep students in the buildings until the threat of lightning has passed. Snack and Lunch 1. Snack: All students will have snack break daily. Please be sure to provide a nutritious, nut free snack for your child that does not need to be re-heated. 2. Lunch: Your child’s lunch bag or box should be clearly marked with her/his name. Due to some food allergies, the lunch must be nut free. Lunches can be heated up. High sugar foods are discouraged. Health Policies All Diener School campers must have current health and medical records on file with the School. All forms are due by Monday, June 3, 2024, and include: o Diener Camp Registration Form o Standing Order Medications, Bug Spray & Sunscreen Authorization Form o Allergy Action Plan-for students with any type of allergy o Asthma Action Plan – for students with asthma o Seizure Action Plan – for students with seizures o Medication Administration Authorization Form -- for any student who will take medication during the school day (prescribed, over the counter or emergency) 1. Accident and Health Insurance: Participants are responsible for their own accident and health insurance when participating in Diener camp programs. 2. Medications (prescribed/OTC, etc.): Please do not send medications with your child. When special circumstances exist, Diener staff may administer oral or topical medication and only when directed in writing by the child’s parent or guardian and supported by appropriate medical documentation. Medications must be in original containers with written instructions for dispensing. A parent or guardian must give the medication directly to program staff and initial the Medication Log. Similarly, a parent or guardian must pick up any remaining medication at the end of the program or DIENER will dispose it appropriately. If you child is prescribed to self-carry an asthma inhaler, epipen, insulin pump, etc. please contact the DIENER office at least three weeks before your child attends DIENER so that a mutually acceptable plan can be developed to meet your child’s medical needs. 3. Known Severe Allergies: The Diener School requests that all parents not send nuts of any kind to school, however The Diener School is not an “allergen-free” environment. It is the responsibility of the parents or legal guardian of a child with a medically documented life-threatening allergy to notify The Diener School prior to the start of school. The school does not have diagnostic responsibility. The School will implement a mutually acceptable Emergency Allergy Action Plan and a letter concerning the nature of the allergy will be sent to all parents in the child’s classroom in order to minimize the known allergen’s presence in the classroom. This letter will not disclose the name of the student. Behavioral Support 1. The Diener School practices a least restrictive behavior intervention policy. Preventative behavior practices and strategies as well as environmental modifications are employed for all campers. Due to the nature of summer camp weeks, it is not possible for all reinforcement systems to fully follow the student throughout the day in all settings. 2. Once preventative strategies and reinforcement systems have been employed, the 1-2-3 Count Up strategy aims to motivate the students to modify their behaviors and follow directions before a short time-out (break). If a camper has more than 3-time outs within a day, parents will be notified. 3. Physical Restraint: If the 1-2-3 Count Up is not effective in reducing the unexpected behavior and the student becomes a danger to himself/herself, others in the school, or school property, The Diener School’s trained staff member(s) may use a physical restraint in accordance with Diener policies. If a physical restraint is employed, a parent will be notified by an administrator and an Incident Report will be completed and sent home. Completed and signed Incident Report(s) will be filed in student’s cumulative file. I have reviewed and accept Diener Camp policies as a condition of registration. I certify that I have provided or will provide complete and accurate information on all registration and health forms. Parent / Guardian #1 First Last Parent/Guardian #1 Signature(Required)Parent / Guardian #2 First Last Parent/Guardian #2 SignatureNameThis field is for validation purposes and should be left unchanged. Δ