Village of Bellevue DEPARTMENT

Village of Bellevue Summer Day Camp

Village of Bellevue Parks, Recreation & Forestry

DEPARTMENT

2828 Allouez Avenue Green Bay, WI 54311

(920) 468-5225

www.villageofbellevue.org

Village of Bellevue Summer Day Camp 2

Welcome… 3

What is Camp… 4

Camp Locations...4

.................... Why Choose Bellevue Day Camp?...4

Camp Registration... 5

Camp Fees… 6

Camp Schedule… 7-9

Camp Themes...8-9

Camp Extras… 10-13

Before & After Camp Fees...10

Trip Fees...11

Trip Descriptions...11-13

Camp Snack… 14

Camp Policies & Procedures… 15-20

Parent/Camper Behavior Contract… 21 *Must be signed and returned to Village Offices before Camp Participation


We are glad you have taken the opportunity to participate in the Bellevue

Summer Camp Program! This handbook has been designed to assist you with

understanding the purpose, procedures, and general operations of the Summer

Camp Program. PLEASE READ THROUGH ALL THE INFORMATION PROVIDED!

Thank you for your interest in our Summer Day Camp Program. Please contact the

Parks, Recreation & Forestry Department with any questions or concerns that are

not covered in the enclosed packet.

Thank you,

Adam Waszak

Recreation Supervisor

(920) 468-5225

[email protected]

CAMP OPEN HOUSE

Join us at Josten or DeBroux Park for a great opportunity

to get your child excited for camp!

Date: Thursday, June 15, 2017

Time: 5:30-6:30pm


Camp Locations & Contact Information: The Summer Day Camp is held at:

Josten Park: 2280 Town Hall Road (Cell: 920.366.8390)

DeBroux Park: 2900 Brighton Place (Cell: 920.366.8389)

Summer Camp Registration:

Online: www.villageofbellevue.org

Village Offices: 2828 Allouez Avenue

Why Choose Summer Camp? Our Summer Camps share one primary goal, GETTING KIDS ACTIVE, OUTDOORS! Our

Summer Camp program is a LICENSED DAY CAMP through the State of Wisconsin. You

can be sure that the camp counselors are dedicated to meeting the needs of the

campers. All of our camp counselors are at least 18 years of age, undergo a criminal

background check, are certified in First Aid and CPR, and receive extensive pre-camp

training.

Your child can comfortably spend the whole day away from home, enjoying being

around many other children in an outdoor environment.

Summer Camp operates nine weekly action packed camps throughout the summer

for CHILDREN AGES 6 TO 12 YEARS of age. Physical activity, self-esteem, social

interaction and skill building are all part of the youth Summer Camp experience.

Camp Counselors will also incorporate the Six Pillars of Character (Trustworthiness,

Respect, Responsibility, Fairness, Caring & Citizenship) as part of the experience.

Please visit the Village’s website to download the parent handbook for more details.

at: www.villageofbellevue.org


Camp Registration:

All camp REGISTRATION FORMS are required and must be submitted no later than the

Thursday prior to your child’s first camp session. Forms are online at

www.VillageofBellevue.org or at the Village Offices, 2828 Allouez Avenue.

The Wisconsin Department of Health and Social Services requires that each

participant have these completed forms on file at each site in case of emergency.

Enrollment: The Summer Day Camp Program is open to children ages 6-12 years of age.

Campers are enrolled when the Village Office receives completed registration form

with payment.

Following enrollment, you will receive a packet containing the following forms:

Camper Code of Conduct (Back of Handbook)

Child Information Form

Bellevue Summer Field Trip Permission Slip

Authorization to Administer Medication Form (If applicable)

Alternate Arrival/Release Agreement (If applicable)

All forms must be completed and returned to the office no later than the Thursday prior

to their first registered week of camp.

T-shirts will be given out to campers on Monday of the first week they attend. For

identification purposes, each participant is required to wear their camp t-shirt on all

field trips.


Cancelation and Refund Policy: Prior to April 15: Full refund, minus $20 processing fee, will be given with a written

notice prior to April 15 for withdrawal from the program.

April 15 thru June 2: Any withdrawal from the camp program with a written notice

prior to June 3rd will be given a full refund minus a $20 cancellation fee per week

cancelled.

NO REFUNDS will be give after June 2!

Fees & Payment Policies: The fee for your first week of camp and any additional charges (i.e. Before &

After Camp Care, Field Trips, etc.) is due in full at the time of registration. If you

are registering for multiple weeks of day camp, the balance of the remaining

weeks of camp will be due on June 1st.

Automatic credit card or debit card

payment must be arranged at

registration.

Additional Fees: The Before/After Camp Care

programs are optional.

For more information go to page 10.

Field trips are optional for campers.

For more information go to page 11.

Tax Info: Day Camp is a licensed childcare program through the State of Wisconsin. The

EIN number you will need to give your tax preparer is 39-1223437.

Camp Fees Per Week - $60 per child for residents

- $74 per child for non-residents

- $150 Resident Family (w/ 3+ children)

- $185 Non-Res Family (w/ 3+ children)

Additional Fees (Optional) - $30 per child for Before Camp Care

- $15 per child for After Camp Care

- $12 per child for field trips


Typical Day at Camp:

Before Camp/After Camp Program: The Village of Bellevue Summer Camp provides

extended child care for an extra fee. CHECK PAGE 10 for more information on service.

Check-in/Check-out: During this time, campers will take part in loosely structured

programming: board games, reading, drawing, and unstructured games.

Opening Ceremony: Campers will meet with staff and will take part in the raising of the

American flag, reciting the Pledge of Allegiance, and choose a Pillar to highlight for the day.

At this time, the campers will also receive any important information regarding the day’s

activities.

Snack: Each child will receive a nutritional snack in accordance with State Law. Parents are

encouraged to provide snack items for the camp. SEE PAGE 14 for more information.

Planned Activities: These activities can include cooperative team sports, group games,

group projects, experiments, environmental learning opportunities, and arts & crafts

projects that encourage children to use teamwork, challenge themselves, learn and have fun.

Activities will be designed to incorporate the Pillar of the day and the theme for the week.

Lunch: This time is for campers to unwind and refuel for the second half of a fun-filled day.

More information about lunch policies can be found on PAGE 20.

Closing Ceremony: Campers will take part in the lowering of the American flag, a short dis-

cussion on how the campers demonstrated the Pillar of the day. During this ceremony, parents

or guardians are welcome to join in after checking out their child.

Daily Schedule: 7:00-9:00 Before Camp Program

9:00-9:15 Check-in

9:15-9:45 Opening Ceremony/Snack

9:45-12:00 Planned Activities

12:00-1:00 Clean up and Lunch

1:00-3:00 Planned Activities

3:00-3:45 Closing Ceremonies/Snack

3:45-4:00 Check-out

4:00– 5:00 After Camp Program


Camp Themes: Day Camp Theme Schedule:

Each week campers will partake in a variety of activities that center around the par-

ticular theme for that week. Listed below are the descriptions for each theme week

and some activities your children can look forward to participating in during these

weeks.

Around the World-Travel around the world without ever leaving camp. Throughout

the week campers will get the opportunity to learn about new cultures, customs,

games, songs, and food. Each day counselors will spend time with their groups

introducing campers to new cultures and exploring the activities they perform on a

daily basis to have fun.

Carnival Craze-Ladies and gentlemen, boys and girls of all ages step, right up and

prepare for a week of high-flying fun playing a variety of carnival-themed games

and maybe make a few of your own carnival games to take home as well.

Design & Construct-Blueprints, inventions, sketches, designing, constructing, and

manufacturing! This week is all about collaboratively designing and constructing

various projects. From bridges that can hold a lot of weight to canisters that can

protect an egg when dropped from extreme heights. Come prepared to get

creative, inventive, and resourceful!

Week Dates DeBroux Park Josten Park

1 June 19-23 Sports of all sorts Space Quest

2 June 26-30 Design & Construct Outdoor Adventure

3 July 10-14 Around the World Goofing with Games

4 July 17-21 Goofing with Games Wacky Water Week

5 July 24-28 Outdoor Adventure Around the World

6 July 31—Aug 4 Wacky Water Week Design & Construct

7 Aug 7-11 Carnival Craze Sports of all Sorts

8 Aug 14-18 Space Quest Carnival Craze

9 Aug 21-25 Summer Aloha! N/A


Camp Themes:

Goofing with Games-Spend the week watching your favorite board games and

game shows come to life at camp. This week your camper will have fun being a

contestant of the Price is Right or playing real life Monopoly. Campers will even

get a chance to invent their own game! Get your game face on and get ready

for the most fun you have ever had playing games.

Outdoor Adventure-Learn about the environment through arts and games. You

will learn about wilderness survival skills, make bird feeders, play games that teach

about the delicate ecosystem we live in, and ultimately discover a new

appreciation for the local plant and wildlife all around us.

Space Quest- Blast off with Bellevue Summer Camp as we have an out of this

world good time learning about space. This week we will make a water rocket,

play asteroid ball, create space ships, learn about constellations and much

more.

Sports of all Sorts- Join us as we explore and play all sorts of sports, ranging from

team sports like football or soccer to the more obscure yard sports like ladder golf

or bean bag toss. Throughout the week campers will not only learn how to play a

variety of sports, but will make their own equipment to play sports at home.

Summer Aloha!-Join us as we celebrate and look back on the friendships we

formed and games we played. This week counselors recreate some of the

campers favorite games and crafts of the summer.

Wacky Water Week- Campers will have the time of their lives taking part in a varie-

ty of games, activities, and crafts that will get them soaked to the bone. Make

sure to bring your swim suit, towel and extra clothes because we guarantee you

will get wet.


Before & After Camp Programs:

Before & After Camp Programs: With the Before Camp Program parents can drop-off their children anytime between 7:00

and 9:00 am. Similarly the After Camp Program allows parents to pick-up their children

between 4:00 and 5:00 pm.

At these programs children will take part in some

structured and self-directed programming.

How do I sign my child up for these

programs?

You can sign up your child for either of these

programs while registering for camp.

How much do these programs cost?

These programs follow the fee schedule shown

below:

Late Pick-up Policy:

If your child has not been picked-up by 4:00 pm

(Not enrolled in After Camp) or 5:00 pm (If enrolled in After Camp) late fee will be applied.

Your child will not be allowed to attend camp until late pick-up fees are paid in full. If a

child is picked up late from camp on 3 occurrences, that child will not be

permitted to attend any further camp

sessions this summer. If your child has not

been picked-up after 31+ minutes and

the staff has been unable to contact

parents/guardians, the proper

authorities will be notified.

Before & After Camp Program

Program Cost/per week

Before Camp Program $30 per child

After Camp Program $15 per child

Late Pick-up Fees:

1-15 minutes late $10 charge per child

16-30 minutes late $15 charge per child

31+ minutes late $25 charge per child


Date Trip Site Date Trip Site

June 21 Ashwaubenon Bowling August 2 Mystery Trip????

*June 27 Timber Rattlers August 9 NEW Zoo

July 12 Barlow Planetarium August 16 Bay Beach

July 19 Willow Creek Park August 23 KROC Center

July 26 Wildlife Sanctuary

Trip Fees:

Field trips are not included in the weekly camp fee. All field trips require an extra

$12.00 fee. Campers are encouraged to attend field trips, but they are not

mandatory. Camp will be closed during the hours of the field trip.

Field Trip Schedule:

b

For more information on these trips, check the Village website or call the Village

offices.

Field Trip Descriptions: June 21, 2017 to Ashwaubenon Bowling

Campers will take a trip to

Ashwaubenon Bowl, where they will

get to bowl a few games with friends

and staff. Shoe rental is included. Please send your child with socks!

June 27, 2017 to Timber Rattlers Game

1, 2, 3 strikes and you’re out! Join us

as we head out to the old ball park to

watch our Wisconsin Timber Rattlers

play at home. Trip includes lawn

seats and a packed brown bag lunch.

Josten DeBroux

Departure 12:30pm 12:15pm

Return 3:00pm 3:00pm

Josten DeBroux

Departure 10:45am 10:30am



Field Trip Descriptions: July 12, 2017 to the Barlow Planetarium &

Weis Earth Science Museum

This week we will be traveling down to

the UW-Fox Valley Barlow Planetarium

and Weis Earth Science Museum. On

the field trip we will take a guided plan-

etarium tour of our solar system while we learn about the planets and stars.

We will also take a tour of the museum where we will learn about the

nature around us.

July 19, 2017 to Willow Creek Park

Join us as we bring the two camps to-

gether to play some of our favorite

games. Campers will have the oppor-

tunity to play some popular games from camp, as well as create new and

exciting crafts.

July 26, 2017 to the Wildlife Sanctuary

This week we will be traveling to the

Bay Beach Wildlife Sanctuary. Campers

will get an up-close look at several native animals, as well as tour the

Sanctuary.

August 2, 2017 MYSTERY TRIP

????????????????????

Parents will be informed of trip details

after sign-up.

Josten DeBroux



Josten DeBroux



Josten DeBroux



Josten DeBroux




Field Trip Descriptions:

August 9, 2017 to NEW ZOO

Campers will get to spend the day

exploring the Zoo’s exhibits and have a

picnic in the Reforestation Camp.

Please make sure to send your camper with gym shoes and plenty of water.

August 16, 2017 to Bay Beach Amusement

Park

Take a ride on the “Zippin Pippin” or

slide down the giant slide. Whatever

your interest, you’re sure to have a good

time on this trip. All participants will receive $5 in tickets to use at their lei-

sure.

August 23, 2017 to Ray & Joan Salvation

Army Kroc Center

Campers will take a trip to Kroc Center,

where they will enjoy playing some great

indoor group games in the gymnasium, splashing around in the indoor pool,

cruising down the water slides, and staying active while playing in the Kroc

Center game room. There will be something for everyone to do. It’s important

that campers bring a swim suit and towel.

All Departure and Return times are approximate. In the event of massive delay the Village Offices will

be notified and notification of approximate arrival time will be posted on the Village website and will

be sent to cell phone via text alert (page 20).

Josten DeBroux

Departure N/A 9:30 am

Return N/A 3:00 pm

Josten DeBroux

Departure 9:30 am 9:15am

Return 3:45pm 3:45 pm

Josten DeBroux




As a part of the Department of Children and Families State Licensing, the Village

of Bellevue is required to provide each child with 2 snacks throughout the day. To

provide snack and maintain affordable fees for the Summer Camp program, we

request your help by signing-up to provide a snack for the site on a day of your

choosing.

When volunteering to make a donation we ask that you provide enough food to

feed 48 campers and only food items from the following State-approved list

below:

Any kind of 100% fruit or vegetable juice

- Individual juice pouches, boxes, jugs, etc.

- Large jars we can pour and distribute.

Crackers with whole wheat or wheat listed as the first ingredient

Examples:

- Wheat Thins

- Goldfish Crackers

- Packs of cheese and breadsticks

- Animal Crackers

- etc.

Cold Cereal

Granola Bars

All donated snacks must be in their original packages and sealed. All snack

donations may be delivered to the camp site. We really appreciate your help in

making this program a healthy and enriching experience for your child.


Absence Policy: If your camper will be absent, please leave a message at the camp site location or

Village Offices no later than 9:15 am the day of the absence. If no message is left the following actions will be taken:

1. Camp staff will call parent/guardian via the camp registration paperwork

to confirm absence for day.

2. If confirmation of absence cannot be made the Recreation Supervisor

and authorities will be notified.

Allergies: All known allergies or any special dietary needs based on medical condition must

be noted on your child’s Registration and Health Form. Staff will be notified of all

camper's allergies. Please talk to staff if your child has special or more serious circumstances.

Child Abuse Policy: The camp staff are trained to spot signs of child abuse, know the appropriate

procedures for responding to the suspicion of abuse, and will be alert to the

physical and emotional state of all children. When any sign of injury or suspected

abuse is detected, the Recreation Supervisor will be notified immediately and a re-

port will be made to the appropriate authorities.

Confidentiality: We will strive to keep information about a child or about an incident involving one

of our campers as confidential as possible. However, the Village is a municipality

which is covered by the public records law and certain documents may be

required to be released upon request or upon order of the court. We will not discuss

incidents involving your child with other program participants or their families unless

it is required by law or the other child was involved in an incident with your child. If

that is the case, information on your child will only be shared to the extent neces-

sary to provide necessary information to the other parent.


Emergency Medical Facility: The hospital we use for emergency care, in the event that such care is needed, is

Aurora BayCare, located at 2845 Greenbrier Rd. Green Bay, WI 54311.

Inclement Weather Policy: Physical activities will be limited when there is a heat advisory, it is raining, or during

severe weather. Indoor activities will be substituted. If an outdoor field trip is sched-

uled and it is a severe weather day, a substitute indoor field trip will replace it.

Injury & Accident Report Policy: Any injury during the course of the day will be documented by the camp staff and

reported to the Camp Coordinator. The Village of Bellevue Accident Report Form

will be utilized for documentation.

In the event of a Serious Injury or Illness:

Emergency personnel will be called first if injury or illness appears life

threatening, then parents/guardians.

Staff will attempt to contact parent/guardians.

- If child must be transported by ambulance, a staff member will ride with

the child, taking registration forms along.

- Camp Coordinator will be notified of accident/injury and will notify

the Recreation Supervisor.


Illness Identification/Procedure: Children with rashes, fever of 100 degrees or above, vomiting and/or diarrhea are

to be sent home.

If a child becomes ill during the camp time:

A parent or authorized person will be called to pick up the child.

While waiting for parent/guardian, the child will be taken to a separate area

and made comfortable.

Lost and Found Policy: A Lost and Found box will be available for all misplaced items found throughout

each day.

Please DO NOT SEND ANYTHING VALUABLE TO CAMP. This includes items of sentimental value.

Please MARK YOUR CHILD’S NAME ON EVERYTHING they bring with

them to camp.

ALL LOST ITEMS WILL BE KEPT FOR 3 WEEKS.

After this, unclaimed items will be cleaned and donated to charity.

Medication Policy: Campers requiring medication shall fill out an AUTHORIZATION TO ADMINSITER

MEDICATION FORM prior to the camper starting camp.

Prescription medication will be ADMINISTERED UPON RECEIPT OF SIGNED FORM

from parent/guardian.

The ONLY OVER THE COUNTER MEDICATICATION THAT WILL BE DISPENSED IS

BENADRYL in accordance with a physician’s note.

MEDICATION WILL ONLY BE RETURNED TO PARENT/GUARDIAN

Any medication not picked up will be disposed of in an environmentally

safe manner.


Newsletters: The newsletters can be picked up on Mondays and Fridays.

MONDAY ISSUE WILL INCLUDE:

Relevant information for that week

Field Trip notes

FRIDAY ISSUE WILL INCLUDE:

Information on what campers have done throughout the week

Pictures from the week

Camper of the week

Office Hours: RECREATION SUPERVISOR: vary from 7:00am-5:00pm during the summer

VILLAGE OFFICE: 7:30am-4:30pm

CAMP SITES: 7:00am-5:00pm.

Open Visitation Policy: Parents are encouraged to visit and take part in activities at Camp at any time.

Parent/Staff Communication: Parents please SHARE ANY INFORMATION REGARDING YOUR CHILD THAT MAY

AFFECT THEIR MOOD OR BEHAVIOR with camp staff as you see fit.

At Bellevue Summer Camp, we welcome the opportunity to talk with parents and

get to know our camper families better. Being partners with parents is the best

way to make camp the most positive experience possible. Any of our camp staff

will be happy to speak with you.


Participation: If campers cannot participate in specific activities for medical reasons, a note

from the parent/ guardian or doctor is required.

Ratios: The State of Wisconsin requires staff to camper ratios to be 1:12 and will be fol-

lowed at the Village of Bellevue Summer Day Camp.

Schedules: LESSON PLANS AVAILABLE EVERY MONDAY morning for parents and guardians to

review.

Activities may vary slightly from day to day.

Search and Confiscation Policy: A camper, and/or the camper's belongings may be searched by Camp staff

whenever they have a reasonable suspicion that a camp rule or law has been

broken.

Any illegal items found will be confiscated.

Sunscreen: PLEASE SEND SUNSCREEN WITH YOUR CHILD EVERYDAY. Your child will have fre-

quent opportunities throughout the day to reapply sunscreen.

Please make sure that sunscreen is less than 1 year old

Supplies Needed: We are always looking for donations of “household junk” such as toilet paper rolls,

coffee cans, jars, etc.

Check newsletters for specific “junk” needed.

Text Alerts: Text alerts are one way in which staff will INFORM YOU OF IMPORTANT NOTICES.

Make sure to add your cell phone number and carrier on the registration form.

These alerts will only be used for important information.


Updating Information: It is the responsibility of parents to INFORM CAMP STAFF OF ANY CHANGES to your

child’s information.

Videotaping/Photographing of Program Participants: Authorized individuals may videotape or photograph groups or individuals for

public relations or educational purposes.

IF YOU DO NOT WANT YOUR CHILD VIDEOTAPED OR PHOTOGRAPHED please let the

camp staff know during the first day at camp.

What to Bring to Camp Every Day: Please dress according to the weather & LABEL ALL ITEMS with child’s name

Wear shoes appropriate for active play and comfortable summer “play

clothes”

A lunch Please pack healthy lunch options.

The State of Wisconsin indicates that lunches should consist of:

- 1 protein source

- 2 vegetables/fruits

- A whole grain source

- Healthy drink (100% Juice)

* If a lunch is forgotten or not provided, the Village will provide a lunch at an ADDITIONAL $10 FEE, that must be paid in full prior to the next day of

camp.

Windbreaker/raincoat/sweatshirt (they may need all 3, watch weather) Water Bottle

* Water is the ultimate hydrator and is our primary drink during the day.

Bug repellent

Sunscreen

A change of clothes

PACK ALL ITEMS IN A BACKPACK

What Not to Bring to Camp: Cell phones Gaming devices

iPods/MP3 players Unnecessary valuables

Inappropriate clothing

Village of Bellevue reserves the right to confiscate any prohibited item!


The goal of the Day Camp Program is to provide a safe, educational, and fun atmosphere for all campers.

Please take time to read through and discuss our policies on proper character conduct as a family, then

take time to sign the contract as this will serve as a guide to disciplinary actions for the summer.

Termination Procedure:

If an incident occurs where a camper conducts himself/herself in a manner that jeopardizes their safety, or

the safety of others, the following steps will be taken:

First Violation: A staff member will discuss the incident with the child. The child may be re-

moved from part or a whole activity. The parent or guardian will be notified of the incident

at the end of the camp day.

Second Violation: A staff member will document the incident via an incident report and dis-

cuss the incident with the child. The child may be removed from part or a whole activity.

The parent or guardian will be notified of the incident at the end of the camp day and

asked to sign the documented incident report.

Third Violation: A staff member will discuss and document the incident directly with the child.

The parent or guardian will receive a phone call and be asked to pick up their child within

the hour.

Fourth Violation: A staff member will discuss and document the issue directly with the child. The

parent or guardian will be contacted immediately to pick up their child within the hour

from camp. A conference will be scheduled with the Department Director, Camp Direc-

tor, Camp Coordinator, and the parent(s) or guardian to discuss a plan of action regard-

ing the poor behavior. The child will be suspended from camp for up to a week.

Fifth Violation: Child will be dismissed and no longer allowed to participate in camp for the

remainder of summer.

Circumstances for Immediate Termination:

Physical Violence – A parent or emergency contact will be called to pick up their child immedi-

ately. A meeting may be necessary and will be determined on a case-by-case basis.

Intentional Leave – If a camper leaves the program area or building intentionally without permis-

sion a suspension or termination may occur, based on the situation.

Sexual or Other Harassment – Parent/guardian will be contacted immediately. Camper will be

prohibited from future camp activities.

Inappropriate Behavior of a child or parent that endangers the participant, other children or

Bellevue staff.

Late Child Pick-Up (more than 3 occurrences).

Please do not hesitate to talk to the site staff or Recreation Supervisor if you have questions or

concerns.

The Village of Bellevue reserves the right to start at the 2nd, 3rd, 4th, or 5th violation depending on the

severity of the incident.

Each case is different and all supervisory staff are approved to make appropriate judgment calls.

I have read and understand the Bellevue Summer Camp policies, procedures, rules and consequences. I

understand that by signing this contract I am obligated to follow the policies and procedures outlined in

the Summer Camp Handbook.

(Child’s Signature and Date) (Parent/guardian Signature and Date)

Participant Names

M/F

DOB Shirt

Size

SUMMER CAMP REGISTRATION FORM

Family Name # of Children to Enroll

Home Phone Cell Phone Email

Street Address City Zip Code Resident ☐ NR ☐

Parent/Guardian Names

PAYMENT INFORMATION

☐ Cash ☐ Check ☐ Credit

Card #:

Exp. Date: ____________________________

Amount Paid: _________________________

CAMP WEEK

LOCATION BEFORE / AFTER

CAMP CARE

FIELD

TRIPS

TOTAL $

WEEK #1

June 19-23

☐ DeBroux (Sports of all Sorts)

☐ Josten (Space Quest)

☐ Before Camp

☐ After Camp

☐ Yes

☐ No

$

WEEK #2

June 26-30

☐ DeBroux (Design & Construct)

☐ Josten (Outdoor Adventure)

☐ Before Camp

☐ After Camp

☐ Yes

☐ No

$

WEEK #3

July 10-14

☐ DeBroux (Around the World)

☐ Josten (Goofing with Games)

☐ Before Camp

☐ After Camp

☐ Yes

☐ No

$

WEEK #4

July 17-21

☐ DeBroux (Goofing with Games)

☐ Josten (Wacky Water Week)

☐ Before Camp

☐ After Camp

☐ Yes

☐ No

$

WEEK #5

July 24-28

☐ DeBroux (Outdoor Adventure)

☐ Josten (Around the World)

☐ Before Camp

☐ After Camp

☐ Yes

☐ No

$

WEEK #6

July 31-Aug 4

☐ DeBroux (Wacky Water Week)

☐ Josten (Design & Construct)

☐ Before Camp

☐ After Camp

☐ Yes

☐ No

$

WEEK #7

Aug 7-11

☐ DeBroux (Carnival Craze)

☐ Josten (Sports of all Sorts)

☐ Before Camp

☐ After Camp

☐ Yes

☐ No

$

WEEK #8

Aug 14-18

☐ DeBroux (Space Quest)

☐ Josten (Carnival Craze)

☐ Before Camp

☐ After Camp

☐ Yes

☐ No

$

WEEK #9

Aug 21-25

☐ DeBroux (Camp Aloha!) ☐ Before Camp

☐ After Camp

☐ Yes

☐ No

$

Totals: $

Liability Waiver: I understand participation in parks and leisure programs involves elements of risk or danger for all participants and may cause

serious injury, death or property loss. I agree to assume these risks for my family and release the Village of Bellevue, its employees, volunteers

agents and other participants from any liability for injuries and damages sustained while participating in these programs.

Signature Date

Child Information Form

Child’s Last Name

Child’s First Name MI Sex DOB

Living Arrangement: ___ lives with both parents, ___ lives with mother, ___ lives with father, ___ lives with Guardian

T-Shirt Size: Home Phone

Address

Cell Phone Number and Carrier (For Text Alerts):

City

State Zip Family Email Address

Parent/Guardian Information Please indicate the order in which to make contact in case of emergency, illness or other unforeseen circumstance by circling 1,2,3 or 4 for the name as well as phone numbers to be called. When choosing the order, please keep in mind each person’s accessibility, as well as that calls will occur between 3:30 pm and 6:00 pm. Name

Home Phone 1 2 3 Cell Phone 1 2 3 Place of Employment Work Phone 1 2 3

Name

Home Phone 1 2 3 Cell Phone 1 2 3 Place of Employment Work Phone 1 2 3

Emergency Contacts Please list emergency contacts in the order in which they should be contacted in case of an emergency. Also indicate in which order to use the phone numbers listed for each emergency contact by circling 1,2, or 3. Name: Address:

Home Phone 1 2 3 Cell Phone 1 2 3 Work Phone 1 2 3 Relationship to Child

Name: Address:

Home Phone 1 2 3 Cell Phone 1 2 3 Work Phone 1 2 3 Relationship to Child

Authorized Pick-Ups The people listed below will be the ONLY people allowed to pick-up the child noted above. Please include parent names on this list. Photograph Identification is required upon pick-up.

Name Address Relationship to Child Phone

1.

2.

Health Information Child’s Physician

Medical Facility Name Medical Facility Phone Number

Medical Facility Address Hospital Preference: ___ Aurora, ___ Bellin, ___ St. Mary’s, ___ St. Vincent

Sunscreen & Insect Repellent Authorization (Insect repellent & sunscreen must be brought from home.) I authorize staff to apply sunscreen to my child Yes No Brand Name:__________________________ SPF Strength:___________

I authorize staff to apply repellent to my child Yes No Brand Name:__________________________ Ingredient Strength:___________

Medical Device Consent Any and all medical treatments, devices, or medications must be provided by parent/guardian. If such devices, medication, or treatments are present at camp, staff must be notified via medication authorization form.

I give consent for my child to use any of the following checked items when necessary:

Inhaler EpiPen Other:____________________________________

Health History Does your child have a history of: ADD/ADHD/Behavioral Disorders Asperger’s Syndrome Asthma Autism

Cognitive Disability Cerebral Palsy/Motor Disorder Diabetes Learning Disability

Gastrointestinal or Feeding Concerns Heart Problems Epilepsy/Seizures

Physical Handicap Sensitivity to Sun Food/Milk Allergies Non-Food Allergies

Other(describe)_________________________________________________________________________

OVER

Health History (Continued) 1. Please describe any health concerns checked above:

2. Triggers that may cause problems (specify):

3. Signs or symptoms to watch for (specify):

4. Action steps for camp staff to take (specify):

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

6. When to consider emergency care:

7. Any additional information that may be helpful to staff:

Please contact Recreation Supervisor if your child has any special medical needs or conditions that camp should be aware of.

Immunization History The following are the minimum required immunizations. Children entering kindergarten must have received one dose of DTP/DtaP/DT after the 4th birthday to be compliant. Measels, mumps, and rubella vaccines must have been received on or after the 1st birthday. List the month, day, and year your child received each of the following immunizations (or attach a separate sheet with immunization records). DO NOT USE AN ‘X’ OR CHECKMARK to indicate it has been completed. Contact your doctor or public health agency to obtain dates if necessary. REQUIREMENTS: 2 yrs. – Kindergarten: At Kindergarten entrance: This Child is not immunized for -4 DTP/DtaP/DT - 4 DTP/DtaP/DT religious reasons.

-3 Polio - 4 polio -MMR - 2 MMR This child is not immunized for - 3 Hep B - 3 Hep B personal conviction reasons. - 3 HIB - 1 Varicella - 1 Varicella

Parental Consent: By signing below you are authorizing that all information provided on this form is accurate to the best of your knowledge.

You have read through and agree to all camp policies and procedures outlined in the Bellevue Summer Day Camp handbook.

You give consent for emergency care or medical treatment to be provided to your child.

Parent/Guardian Signature:___________________________________________________________ Date:___________________________

TYPE OF VACCINE FIRST DOSE mm/dd/yy

SECOND DOSE mm/dd/yy

THIRD DOSE mm/dd/yy

FOURTH DOSE mm/dd/yy

FIFTH DOSE mm/dd/yy

DTP/DTaP/Td Diphtheria Tetanus-Pertussis

(Whooping Cough)

Polio

Haemophilus influenza (HIB)

Hepatitis B

Measels, Mumps, Rubella (MMR)

Varicella (Chicken Pox)

Bellevue Summer Camp Field Trip Permission Slip

Instructions: Complete the form and submit along with registration packet.

I give my child permission, (Child’s Name)

to attend the field trip(s) marked below: (Please check all field trips your child will attend)

I understand that all return times are approximate. All transportation on trips will be contracted through First Student Bus Company. The Village of Bellevue Summer Camp staff will remind you of the field trip specifics in the Monday newsletter the week of the trip. I authorize the Village of Bellevue Summer Camp to take my child on all above marked field trip(s) on the date(s) indicated.

6/21: Ashwaubenon Bowl Departure: 12:15 pm Return Time: 3:00pm Cost: $12 ( Includes: Transportation, 2 hrs bowling)

6/27: Timber Rattlers Game Departure: 10:30am Return Time: 3:00 Cost:$12 (Includes: Transportation, Brown Bag Lunch, Admission)

7/12: Barlow Planetarium Departure: 9:15am Return time: 3:00pm Cost: $12 (Includes: Transportation, Tour)

7/19: willow Creek Park Departure: 9:45am Return Time: 3:00pm Cost: $12 (Includes: transportation)

7/26 Wildlife Sanctuary Departure: 10:45am Return Time: 3:00pm Cost: $12 (Includes: Transportation, Guided Tour)

8/2 Mystery Trip Departure: 11:30am Return: 3:00pm Cost: $12

8/9: NEW Zoo Departure: 9:15am Return Time: 3:00pm Cost: $12 (Includes: Transportation, Admission)

8/16: Bay Beach Departure: 9:15am Return Time: 3:00 Cost: $12 (Includes: Transportation, $5 in Tickets)

8/17: Kroc Center Departure: 9:30am Return Time: 3:00pm Cost: $12 (Includes: Transportation, Day Passes)

SIGNATURE- Parent or Guardian Date Signed

Bellevue Summer Camp Field Trip Policies & Procedures

Only one permission slip per child is needed for the summer.

Field trips are subject to change or cancellation due to weather or other factors.

On field trip days, camp sites will be open only to those camp participants who have registered for the field trip.

Each participant is REQUIRED to wear their camp t-shirt on the field trip.

All participants’ health forms, emergency contact information, & needed medication will be transported on all field trips by the Camp Coordinator.

Staff will be available by cell phones during all field trip activities.

A portable first aid kit will be transported on all field trips.

Please pack a DISPOSABLE LUNCH on all field trips (unless noted).

Campers ARE NOT permitted to bring extra money with them on all field trips (unless noted).

BE PROMPT! Please have your child arrive no later than 9:00 am.

SUMMER DAY CAMP

MEDICATION AUTHORIZATION FORM MEDICATION REQUIREMENTS

Prescription medications must be in the original container with the pharmacist’s label marked with the prescription number, date, child’s name, and physician’s name.

All non-prescription medications (OTC’s) must be labeled with child’s name.

Please give all medications to camp staff upon arrival at your camp.

Child’s name

Authorization is effective from until . (Start Date) (End Date) I authorize the administration of by day camp staff. (Name of Medication)

Instructions for administration of medication (dosage instructions):

*All remaining medication will be returned to parent/guardian at the end of each week. If medication is not picked-up the Village of Bellevue will dispose of medication in an environmentally safe manner. Parent/Guardian Signature: Date:

RECORD OF ADMINISTRATION (TO BE FILLED OUT BY CAMP STAFF) Staff Name Date Name of Medication Dosage Time

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Alternate Arrival/Release Agreement

Instructions: Complete this form for placement in child’s file when child will arrive at the camp site

from school, home or other activities, or depart from the camp site to go to school, home or other activities, and the child will not be accompanied by a parent or other previously authorized person. This form should be updated as information changes. Periodic review with the parent/guardian is recommended to ensure safety.

ARRIVAL INSTRUCTIONS

My child (Child’s Name)

will arrive at (Name of Camp Site)

from (School, home or other activity)

by way of (Walking, bicycle, bus, car pool, etc. Be as specific as possible) at AM OR PM (Child must sign in to camp no later than 9:30 am) (Time of Arrival)

on Monday Tuesday Wednesday Thursday Friday My child will arrive from this destination with OR without camp supervision. RELEASE INSTRUCTIONS

My child (Child’s Name)

will leave (Name of Camp Site)

by way of (Walking, bicycle, bus, car pool, etc. Be as specific as possible) to go to

(School, home or other activity) at AM OR PM (Child may no sign out until 3:30 pm) (Time of Arrival)

on Monday Tuesday Wednesday Thursday Friday

My child will arrive from this destination with OR without camp supervision. ADDITIONAL INSTRUCTIONS I understand that I am responsible for notifying the camp of any changes in this schedule such as vacation, etc. SIGNATURE-Parent Date Signed (mm/dd/yyyy)

VILLAGE OF BELLEVUE

BANK CARD OR CREDIT CARD DRAFT AGREEMENT

Summer Camp Program

Child(ren)’s Name:

Draft Account Information:

Master Card Visa American Express

Name as it appears on the card:

Account Number: Expiration Date:____________ Security Code:__________

Authorization:

I hereby authorize my financial institution to withdraw the remaining amount owed for my child’s camp regis-

tration from the account listed above.

1. Payment will be made on June 1.

2. It is my responsibility to notify the Village of Bellevue Leisure Services Department immediately of any ac-

count change or closing and to provide the Village of Bellevue Leisure Services Department with current

account information.

3. The Village of Bellevue reserves the right to refuse registration into programs or entrance into facilities if

payments are delinquent. Full payment of delinquent payments will be required for reinstatement into

programs.

Parent/Payee Signature: Date:

RETURN THIS DRAFT AGREEMENT ALONG WITH YOUR

COMPLETED CHILD INFORMATION FORM(S)

Village of Bellevue DEPARTMENT

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