Camp Fly High at Madonna Learning Center

7007 Poplar Avenue Germantown, Tennessee 38138

Phone: 901.752.5767 Fax: 901.752.5039

CAMPER APPLICATION Date of Application:

CAMPER APPLICANT INFORMATION Full Name: Nickname:

D.O.B. _____________

Age: Gender: M F

Home Address:

City: State: Zip Code:

Home Number: ( ) - Cell Number: ( ) -

E-mail Address:

Current School: Last Grade Completed:

Please Circle T-Shirt Size: YS YM YL AS AM AL AXL AXXL AXXXL

Camper’s Diagnosis:

Individualized Needs (Please attach additional page, if necessary):

CONTACT INFORMATION

Mother’s Name:

Home Phone:

Cell:

Work:

E-mail:

Father’s Name:

Home Phone:

Cell:

Work:

E-mail:

CAMP INFORMATION

What is Camp Fly High?

• Camp Fly High is a recreational summer camp for individuals with special needs in the Memphis community. Our goal is to provide each camper with a fun-filled summer experience with activities individualized to meet the needs of each camper.

Who can attend Camp Fly High?

• Individuals 4 years old and up. • Open to all children or young adults with special needs. • Campers are not required to be students of

Madonna Learning Center.

When is

Camp Fly High 2021?

Monday – Friday from 9:00am to 3:00pm • Week 1: June 7 - 11 • Week 2: June 14 - 18 • Week 3: July 12 - 16 • Week 4: July 19 - 23

Where is Camp Fly High 2021?

• Madonna Learning Center 7007 Poplar Ave. Germantown, TN 38138

OTHER INFORMATION • Please submit your application by email to • kgilbert@madonna-learning.org , or through drop off, mail, or fax to

MLC. • You may drop off payment at MLC or send cash or check to MLC.

Please make all checks out to ‘Madonna Learning Center’. • Once your application is submitted, you will receive a follow-up e-mail

within one week.

CAMP SIGN-UP

Please check the corresponding box for each week of camp you would like to attend.

X Camp Week Camp Dates Weekly Cost 1 June 7 - 11 $200

2 June 14 – 18 $200

3 July 12 – 16 $200

4 July 19 - 23 $200

*Enrollment Fees*

50% of the summer total is due May 3, 2021.

These are non-refundable and guarantee your child’s spot at camp. Remaining Balances are due by June 7, 2021.

*If your child can no longer attend camp for any reason, you will be refunded the remaining balance if we are able to fill your child’s spot for the week.

If needed, individualized payment plans can be made. Please contact MLC at 752-5767 for more information.

Number of Weeks

Selected

Weekly Tuition Total Cost for Summer 2020

Enrollment Fee (50% or

more)

Remaining Balance

X $200.00

Camp Fly High Information

Camp Times

Monday – Friday 9:00am – 3:00pm **Please note any days that you know your child will be absent from camp. Pick up/Drop off The doors will open at 9:00am, and pick-up will begin at 3:00pm. You will enter the Madonna campus from the East entrance and drive all the way around the school until you reach the gym doors. There will be a sign that says drop off. Please pull all the way up so that we can load and unload two cars at a time. You will exit campus through the West entrance.

Lunch Your child will need to bring his or her own lunch each day, except Friday’s. We try to have lunch sponsored on Friday’s, so please let me know if you know of anyone who would want to sponsor lunch one week! J

Water Days We will have water day at the school every Tuesday, Thursday, and Friday. Due to Covid-19, we will not be going off campus to swim this year. Please send your camper in their bathing suit with a change of clothes on water days. We also ask that each camper send in sunscreen and a towel with his or her name labeled on it.

Themes *subject to change* Below includes each week’s theme. Unfortunately, due to Covid-19, we will not be attending field trips this summer, unless CDC guidelines change. Feel free to dress up based on each theme throughout the week! Week 1 - Animal Planet Week 2 - Disney/Superhero Week 3 - USA Week 4 - Under the Sea

Please fill out this form carefully pertaining to the needs of your child. This will help our camp staff have a better understanding of not only your child’s needs, but also his or her likes/dislikes so that camp is fun and enjoyable!

Please feel free to attach additional information that could be helpful (behavior plans, etc.)

• Your child’s individual needs/differences:

• Your child’s diagnosis:

• The best way to communicate with your child/the way your child best

communicates their needs:

• Your child’s strengths:

• Your child’s weaknesses:

• Your child’s interests:

• Your child’s dislikes:

• What possible situations or stimuli may cause your child to be distressed/anxious?

• What are some common behaviors that the camp staff should be aware of when working

with your child?

• What interventions or methods can be used to maximize desired behaviors/

responses?

• What interventions or methods can be used to minimize undesirable behaviors/

responses?

• Please list any other concerns/comments pertaining to your child. This may include

specific medical, social, and/or behavioral needs.

• What are your expectations and/or goals for your child this summer at camp? What ideas

do you have that would help the camp staff fulfill these expectations or goals?

PICK-UP INFORMATION Please list the names and numbers of individuals that are given consent to drop off and pick up your child during camp this summer.

Name Contact Number Relationship to Child

Madonna Learning Center AUTHORIZATION FOR PHOTOGRAPH RELEASE FORM

Name of Camper:

Name of Parent: Address:

I hereby give Madonna Learning Center, Inc., my consent to photograph and/or

videotape my child, ,

Check one: O With first name only or O With full name or O Without name

For: (check all that apply) O Educational or informational purposes, including O Display at fundraising events O Group photo of all students and trainees O Website

A photocopy of this authorization is as valid as the original. I understand that this

release remains current and valid for one year from the date signed or until . I

understand that I may withdraw this consent at any time via written request.

Date: / /

Signature of Parent/Legal Guardian

Signature of Representative of Madonna Learning Center,

Prescription Drug and Non-Prescription Drug Authorization

All medications should be limited to those required during school hours and necessary to maintain the student’s enrollment and attendance in school. All prescription drugs must be in the original, pharmacy labeled container. All non-prescription drugs must have original label listing ingredients, as well as a dose schedule and your child’s name on the container.

Name of Camper:

Parent/Guardian:

Address:

Emergency Phone #’s:

Parent/Guardian:

Phone Number:

Name of Prescription:

And reason needed:

Dosage:

Time to be given: ___________ {Required by ordering physician}

Prescribing Physician:

I hereby authorize Madonna Learning Center to dispense: as directed above.

{Name of medication}

Parent/Guardian Signature: ____________________________________ Date: _________ All changes in prescription medication must have written authorization from the licensed physician and parent.

Madonna Learning Center Accident Waiver and Release of Liability Form Camp Fly High

In consideration for the acceptance of (camper) as a participant of

Camp Fly High 2021, and the services to be provided by Madonna Learning Center in

connection with Camp Fly High, I confirm my understanding that:

• I have read any rules, conditions, and/or requirements connected with

participation in Camp Fly High;

• Ongoing participation in Camp Fly High is at the discretion of the Camp Fly

High Director;

• I will attend the times and weeks that are filled out on the application;

• I agree to waive, discharge claims and release from liability, Madonna Learning

Center, and the staff and volunteers of Camp Fly High, its Board of Directors

members, and any other agents, from any and all liability on account of, or in any

way, resulting from injuries and/or damages connected with activities of Camp Fly

High. I further agree to hold harmless Madonna Learning Center, Camp Fly High,

its directors, employees, and/or agents from any claims damages, injuries, or

losses caused by my own negligence or action.

Name: Signed: Date: _______________ If you are a minor (under age 18), your parent or legal guardian must sign this agreement on your behalf.

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I hereby agree and consent to the foregoing agreement on behalf of the minor below. Name of Minor: Age: Signature of Parent/Guardian: Date:

HEALTH AND SAFETY GUIDELINES

CAMP 2021

To ensure the safety of all our students/adults, families and staff, we must follow the guidelines of the Center for Disease Control issued by the Health Department. Please do not send your child or adult to Madonna Learning Center if he/she exhibits any of the guidelines listed below. If, on arrival, a client appears ill and/or exhibits any of the guidelines listed below, Madonna staff will request that the student/adult return home and not enter the school building. Should a student/adult become sick and/or exhibit any of the guidelines listed below, while at Madonna Learning Center, parents or emergency individuals will be contacted. The student/adult must be picked up from Madonna Learning Center within 30 minutes (if residing within Shelby County) or 60 minutes (if residing outside Shelby County).

The guidelines are as follows:

1. Fever free without use of fever reducing medicines (Tylenol Advil...) for 24 hours. Normal temperatures are 98.6 oral, 99.6 rectal, and 97.6 axillary (under the arm).

2. No vomiting and/or diarrhea for 24 hours (bowel movements and food and fluid intake should be back to normal). 3. No colored drainage from any body part (this includes eyes, ears, nose and sores). If a child or adult has been on

antibiotics for 48 hours and still has colored drainage (yellow green or brown), they may return to program. 4. No rashes of any sort unless seen by a doctor and the doctor has written a note stating that the rash is not contagious. 5. Vigilant hand washing (soap and water) before and after toileting/changing diapers (this includes the child’s hands),

and before all meals including snack

**This is the best way to prevent the spread of infection**

It is very important that all families and staff use their best judgment. If you or your child is not eating, drinking, sleeping normally, or still “run down”, the body’s resistance is still low and an infection with a different organism (“bug”) is very likely.

Please remember that even if on an antibiotic, one can still catch a virus.

**Masks will be required at camp unless we are told otherwise by the CDC**

Hand sanitizing Stations are located around the building, hand washing practices will be followed along with social distancing guidelines.

Please find the attached waiver that each camper must have signed by a parent or guardian before attending Camp.

If you have any concerns or questions, please contact the school office.

Madonna Learning Center

Waiver and Release

I/we, ________________________________________, the parent(s)/guardian(s) (Legal

Representatives) of _____________________________, agree to allow my child to participate in activities and programs at Madonna Learning Center hereinafter “Madonna”), and in consideration for the opportunity for my child to participate in Madonna programs and activities for other good valuable consideration, the receipt and sufficiency of which are hereby acknowledged, agree as follows: 1. COVID-19. The novel Coronavirus (“COVID-19”) has been declared a global pandemic and is extremely contagious and believed to spread mainly from person-to-person contact. Madonna is following federal, state, and local guidance and has put in place preventative measures to reduce the spread of COVID-19; including, but not limited to, cleaning procedures recommended by the CDC. However, Madonna cannot guarantee that you or your child will not become infected with COVID-19. Further, attending the Camp could increase your risk and your child’s risk of contracting COVID-19. 2. Release of Liability. As Legal Representative and on behalf of my child, I hereby forever release, waive, covenant not to sue, discharge, and hold harmless Madonna, its trustees, officers, employees, staff and agents of any kind thereof (hereinafter collectively the “Released Parties”) any and all liability, loss, damage or expense related to the COVID-19 pandemic arising from or out of my child’s participation in any summer camps, activities or programs at or provided by Madonna, transportation provided by Madonna, or the use of Madonna facilities, equipment, or materials including, without limitation all costs, damages, claims or assertions of any kind or nature (including attorneys’ fees, costs and expenses) respect to which I, my child or my family, estate, heirs, successors or assigns might have or could or might have against the Released Parties. 3. Release of Liability. Third Parties. As Legal Representative and on behalf of my child, I hereby forever release, waive, covenant not to sue, discharge, and hold harmless Madonna and the Released Parties from any and all liability, loss, damage or expense related to the COVID-19 pandemic, including, but not limited to, bodily injury or illness to myself or my child, including death, caused by any acts or omissions of any kind or character whatsoever of any third parties related to, or connected in any way with any summer camps, activities or programs at or provided by Madonna, transportation provided by Madonna, or the use of Madonna facilities, equipment, or materials, including without limitation any costs, damages, claims or assertions of any kind or nature (including attorneys’ fees, costs and expenses) with respect to which I, my child or my family, estate, heirs, successors or assigns may claim against the Released Parties.

4. Indemnity. As Legal Representative and on behalf of my child, I agree to indemnify, defend, and hold harmless the Released Parties from and against any and all costs, expenses, damages, claims, lawsuits, judgments, losses, and/or liabilities (including attorney’s fees, costs and expenses) arising either directly or indirectly from or related to any and all claims made by or against any of the Released Parties due to bodily injury, death, loss of use, monetary loss, or any other injury from or related to my or my child’s participation in summer camps, activities or programs at or provided by Madonna, transportation provided by Madonna, or the use of Madonna facilities, equipment, or materials, whether caused by the negligence of the Released Parties or otherwise specifically related to COVID-19. 5. Assumption of Risk. I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child and I may be exposed to or infected by COVID-19 by attending Madonna and participating in Madonna’s and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand and hereby acknowledge, independently of any advice or representation made by Madonna, that participation in activities or programs at Madonna during the COVID-19 pandemic presents certain risks beyond Madonna’s control, and which may exist regardless of whether Madonna controls or attempts to control such risks and even if Madonna exercises the utmost care in trying to prevent anyone from getting injured or sick. I am permitting my child to participate in activities and programs at Madonna with this understanding and hereby knowingly and voluntarily assume all risks of injury, illness, death or damage related to COVID-19 which may arise as a result of my child participating in activities or programs at Madonna Learning Center. My child’s attendance and participation in programs and activities at Madonna is voluntary, and I understand and hereby acknowledge that I may choose to not have my child attend Madonna, or I may discontinue my child’s attendance at Madonna at any time in light of the risks I am assuming hereunder. 6. Madonna’s Rules and Regulations. I acknowledge and agree that Madonna, and its board members, officers, faculty, staff or agents as Madonna deems necessary, shall have the authority to establish rules and regulations regarding my child attending and/or participating in activities at Madonna. Specifically, Madonna can disallow my child’s attendance or participation in activities at Madonna if it is determined that my child has symptoms of COVID-19. To that end, I agree to permit Madonna to take my child’s temperature upon arrival at Madonna and at any other time that my child is at a Madonna facility. I further agree to monitor my child’s temperature and condition before allowing him or her to participate in any activities at Madonna Learning Center or sponsored by Madonna Learning Center and agree that I will not allow her to participate in any Madonna activity if my child is showing any sign of illness. I agree that my child and I will follow and be bound by the rules and regulations contained in this paragraph and all other Madonna rules and regulations. 2020-21

7. Insurance. I understand and hereby acknowledge that Madonna has no insurance that will pay for, or reimburse me for, any expenses of any kind which I may incur for treatment of illness or injuries sustained while participating in any programs at Madonna. I hereby assume all responsibility for any such expenses. 8. Governing Law and Severability. I agree that this Waiver and Release shall be governed by and construed in accordance with the laws of the State of Tennessee. The terms and provisions of this Waiver and Release shall be severable, such that if a court determines any term of this agreement to be illegal, unenforceable or in conflict with applicable law governing this Waiver and Release, the validity of the remaining portions shall not be affected thereby. In the event of any dispute, the prevailing party shall be entitled to recover attorney’s fees and costs. 9. Representations. (i) I am an adult, and I am the parent/guardian of ________________________________; (ii) I have the legal capacity to execute and to be legally bound by this agreement with Madonna Learning Center and waive certain of my legal rights as provided herein; and (iii) I have read each paragraph and fully understand the terms and conditions of this Waiver and Release and have been provided with the opportunity to discuss it with anyone of my choosing, including a lawyer. Print Full Name of Parent/Legal Guardian ____________________________________________ Signature of Parent/Legal Guardian: ______________________________Date: _____________ Print Full Name of Parent/Legal Guardian____________________________________________

Signature of Parent/Legal Guardian: ________________________________Date: ___________