CSATUSA - FY19 - Orlando Enrollment - 11/21/19

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Camp SAY Across the USA: Orlando

November 21, 2019

Please complete this application to enroll your child in this FREE day camp!

Camper Information

This Camp SAY Across the USA: Orlando online enrollment application must be completed by a parent or guardian. If you have any questions, please contact Kerry O'Connor at 202.919.4848 or Kerry@SAY.org.

Camper Name*

First Name

Last Name

Child's Gender*

Female Male

Other:

If you have selected other, please tell us more.

Does your child stutter?*

Yes No

Other:

If you have selected other, please tell us more.

Child's Date of Birth *

Campers must be 8-18 years of age, as of November 21, 2019 to participate.

Camper's Grade in School (for the 2019-2020 school year)*

Child's School

How does stuttering currently impact your child's life?

Why is SAY/Camp SAY Across the USA: Orlando important to your family?

Please provide your child's T-Shirt size?*

Departing from Camp SAY Across the USA: Orlando

For Camp SAY Across the USA: Orlando, SAY staff has my consent to check out my child from camp in the following way:*

My child has my permission to travel to and from Camp SAY Across the USA: Orlando without parent supervision. My child will be picked up by a parent/guardian. Campers will only be released to approved parents/guardians listed below, unless otherwise specified in writing.

Please list ALL parents/guardians approved to pickup your child from camp (including yourself):

Approved Parent/Guardian #1*

First Name

Last Name

Approved Parent/Guardian #1 Relationship to Camper*

Approved Parent/Guardian #1 Cell Phone*

Approved Parent/Guardian #2

First Name

Last Name

Approved Parent/Guardian #2 Relationship to Camper

Approved Parent/Guardian #2 Cell Phone

Approved Parent/Guardian #3

First Name

Last Name

Approved Parent/Guardian #3 Relationship to Camper

Approved Parent/Guardian #3 Cell Phone

Emergency Contact Information

Please provide two additional emergency contacts below (in case we are unable to reach you) in the unlikely event of an emergency.

Contact 1*

First Name

Last Name

Relationship to Camper

Cell Phone*

Contact 2*

First Name

Last Name

Relationship to Camper

Cell Phone*

Terms & Conditions

In accordance with applicable federal laws, SAY provides equal opportunities to employees and applicants without regard to age, race, religion, ethnicity, veteran status, disability, gender identity, or sexual orientation.

Please Read...

TERMS OF ENROLLMENT
Camp SAY Across the USA: Orlando

1. Camp SAY Across the USA: Orlando enrollment is FREE and includes all day camp activities offered* and by signing below you are giving permission that your child may participate in all camp activities. Please contact Kerry O’Connor at Kerry@SAY.org or 202.919.4848 with any questions.
*Note: Transportation to and from camp is not included. Camp SAY Across the USA: Orlando is a Day Camp and SAY does not provide overnight accommodations.

2. The parent or legal guardian enrolling this child for Camp SAY Across the USA: Orlando certifies that the child is both physically and emotionally healthy.

3. In the event that your child requires special medical attention in a day camp environment, please contact Kerry at Kerry@SAY.org or 202.919.4848, prior to enrollment to ensure we can provide the medical care your child would need and that we have the appropriate medical personnel.

4. I fully understand that the Camp reserves the right to dismiss, in its sole discretion, a camper whose condition, conduct, influence, or behavior is deemed by the Camp unsatisfactory or detrimental to the best interest of the Camp or who violates the Camp Rules and Regulations. I, as the parent/guardian, also give Camp SAY Across the USA: Orlando Staff permission to search the camper's belongings if there is reasonable suspicion that the camper may be in possession of prohibited items.

5. The camp is not responsible for campers' equipment or personal belongings while at camp.

6. Gratuities, in any form, for staff members or camp personnel, are prohibited. Parents are expected to adhere to this important camp regulation.

7. Any claims in connection with this agreement and/or the camp must be made in New York, NY as the sole forum.

8. IN THE UNLIKELY EVENT OF A MEDICAL EMERGENCY, I hereby give permission to an Orlando Hospital or other medical facility selected by the Camp Director to hospitalize, secure proper treatment for, and order injections, anesthesia, or surgery for the child named above. Every effort will be made by Camp SAY to immediately contact parents/guardians in the event of an emergency. If you refuse to sign a Permission-to-Treat form for religious or other reasons, please contact Kerry O’Connor at Kerry@SAY.org or 202.919.4848 to sign an alternative form. Should any such medical care be required, I understand that I am financially responsible for such expenses.

Stuttering Association for the Young, Inc. Release

Please read the following completely and thoroughly.

A Photographer/Videographer may be on-site to capture camp and other related activities. SAY may also create a Camp SAY Across the USA: Orlando blog - similar to the blog used for SAY’s 2-week summer camp, Camp SAY (campsay.tumblr.com) - where parents, family, friends, and others can follow the camp fun. SAY may also utilize camp photos for marketing or other purposes, as well.  

I, as the legal guardian of the child named above, hereby confirm the consent therefore given the Stuttering Association for the Young with respect to its photographing and recording my child in connection with any camp-related activities, and I hereby grant to the Stuttering Association for the Young, their successors, assigns and licensees the perpetual right to use, in any manner or in any media currently existing or which may be developed in the future, as they may desire, all video, publications, still and motion pictures and soundtrack recordings and records which the Stuttering Association for the Young may make of my child or of my child's voice, or any works created by my child and the right to use his/her name or likeness in or in connection with the exhibition, advertising, or any other use of such motion picture or recording, all video, publications, still and motion pictures and soundtrack recordings and records. I further release all exclusive rights to or ownership of any songs, films, music, scripts, poems, or choreography that my child has created or helped to create in conjunction with representatives and/or members of the Stuttering Association for the Young, or while participating in this camp’s programming, and acknowledge full ownership to the Stuttering Association for the Young. Furthermore, I grant the Stuttering Association for the Young permission to copyright all aforementioned materials in its name. I will not seek compensation from the Stuttering Association for the Young for my child's involvement in and camp-related projects or from works created by him/her. I further give permission and consent that any such photographs may be published and used by the Stuttering Association for the Young, and their agents to illustrate and promote the camp experience.

Signature - By signing you agree to the Terms & Conditions above and the Method Agreed to Above for Picking Your Child Up from Camp SAY Across the USA: Orlando*

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Please complete this application to enroll your child in this FREE day camp!

Camper Information

Parent/Guardian Information

Departing from Camp SAY Across the USA: Orlando

Emergency Contact Information

Terms & Conditions

In accordance with applicable federal laws, SAY provides equal opportunities to employees and applicants without regard to age, race, religion, ethnicity, veteran status, disability, gender identity, or sexual orientation.