SUMMER CAMP 2023 Preseason Packet - cloudfront.net

SUMMER CAMP 2023
 Preseason Packet

Table Of Contents
Table Of Contents 2

Items to bring to camp 3

Lost and Found 3

Daily Procedures for Attending Camp 4

Payment Procedures for Camp 5

Medical Policies and Procedures 6

Behavior Management Policy 7

Camp Schedule and Hours 8

Aquatics 9

Camp Groups, Activities & Program Areas 10

Food & Refreshments 11

Technology Use Policy 12

Contact Information 15

Physical Form 16

Authorization for the Administration of Medication 17

Sunscreen Application and Off-Site Permission Form 18

Sunscreen Opt-Out Form 19

Credit Card Authorization Form 20

COVID Waiver 21

Parent Camper Agreement Contract 22

 2

Items to bring to Camp
Each day your child should bring a backpack with the items they need for camp, including the
following:
 ● Sunscreen
 ● Lunch/Snacks
 ● Water Bottle
 ● Bathing suit
 ● Towel
The campers will have a designated area to keep their belongings throughout the day, and along
with their counselor, it will be their responsibility to maintain this area. It is very important for
your child’s personal belongings to be labeled so they do not get lost.

Lost and Found
We will display the items left behind on a table in the front lobby so that they may be easily
identified and retrieved. We bring items to Goodwill on a weekly basis. Please be sure to check
lost and found regularly.
Personal Electronic Devices and Toys
Personal electronic devices and toys are not permitted at camp. If they are brought to camp,
staff will hold these items and return them at the end of the day.

What to Wear to Camp
Camp is very active and all campers should be dressed to participate in the activities of the day.
Comfortable shorts or pants and tee shirts are ideal for campers to wear each day.

Campers must wear closed toe shoes to camp each day. Sandals such as Keens or crocs that
have a closed front foot are acceptable. Flip-flops, slides or other shoes that have an open toe
should not be worn to camp; campers may bring these in their backpacks to wear on the pool
deck only.

Sunscreen
We suggest that campers apply sunscreen in the morning before arriving at camp. Our Staff will
remind campers to apply sunscreen several times throughout the day especially before swim
time.
You must provide sunscreen for your child on a daily basis. The Club staff will work with all
campers to ensure proper usage. We do have sunscreen on campus for certain situations, such
as if a child forgets his or her sunscreen or runs out. The active ingredients in the sunscreen are
listed at the back of this packet on the Sunscreen Opt-out Form (page 16) which includes an
option to request that your child NOT have sunscreen applied by staff. The Sunscreen
Application and Off-Site Permission Form (page 15) gives staff permission to assist with the
application of sunscreen. If you prefer that your child not use our sunscreen for any reason, you
must complete the Sunscreen Opt-out Form.

 3

Daily Procedures for Attending Camp
Drop-off
Because we do not have parking for all campers’ families in our main parking lot, our driveway is
designed to allow parents to pull in, stop at the designated stop, and drop-off and pick-up their
children without leaving their cars. The vehicles travel in a circular pattern. Our staff is available
in the driveway to help locate your children, and to help facilitate their arrival and departure.
Please pull all the way forward to allow for more cars to enter the driveway.

Please turn off your car while waiting. We have adopted a no-idling policy to help with air
quality.

Pick-up
Our daily schedule is structured to facilitate pick up from camp beginning at 4:00 pm. All
campers will be out of the pool by 3:45 pm allowing them to change and be ready for pick-up.
Even with proper scheduling it can sometimes take time for campers to collect their things and
get to the car. If you need to be somewhere following pick-up, please allow adequate time for
this process.
If you arrive for pickup prior to 4:00 pm, campers will be in structured activities on the Boys &
Girls Club campus. Please allow for additional time as your child may not be ready quickly.
Campers MUST be picked up by 5:00 pm or 6:00pm for extended day campers. We allow for a
5-minute grace period. After the grace period, families will be billed $20 per every 15 minutes
that they are late, and payment will be collected at pick-up. Families will be allowed THREE (3)
late pick-ups throughout the Summer, after that the child will be removed from the Camp.
Campers must be picked up on time.
Check-In
Upon arrival each morning it will be the camper’s responsibility to check-in at our designated
spot located outside the front entrance. They will then proceed to their designated area to
check-in with their group leader.

We have additional staffing at the check-in area to assist younger campers with the check-in
process. This allows them to check in without assistance from a parent or guardian. This helps
parents to use the driveway drop off without concerns for assisting with the check-in process.

Campers who are not pre-registered will need to pay for camp at check in and will be charged
an additional fee for same-day registration.

Payment for lunch can be made in the morning upon check-in.

 4

Parking
If you need to come into the Club, please park in a designated parking spot. Do not leave a car
unattended in the circle. If the parking lot is full, parking is available in the municipal parking lot
adjacent to the Club parking lot on Governor Street.

Payment Procedures for Camp
Making Timely Payments/Credit Card Authorization
Payment for camp is due prior to the start of each weekly session. Please make every effort to
have your balance paid off by the Thursday prior to the start of your child’s camp session. If your
child is a full summer camper, please have the equivalent of a week paid by the Thursday prior
to each new week. For instance, if your child is attending camp the week beginning Monday July
10th, payment should be made by Thursday July 6th.

In order to assure camp balances are paid in full; all registrations that are made with a partial
payment will require a credit card authorization form. This form is included in this packet. All
camp balances not paid in full will be charged on the authorized credit card after September 1st.
The form must be completed for your child to attend camp.

Payments may be made online, by mail or in person via check or credit card.

Parents/Guardians of campers who attend camp and have not paid will be contacted by our
Office & Finance Director for payment.

Registration and Fee Policy 2023
A deposit must be made on every registration in order to hold your child(ren)’s place at camp.
All deposits are non-refundable. Camp fees must be paid prior to your child’s first day of camp.
Full Summer campers must have the current week paid.

All campers should be registered for camp before the Friday prior to the following week’s camp.

Late pick-up fees will be collected at pick-up.

If you have any questions about this policy, please contact the Office & Finance Director, Gerry
Hawaux at ext. 16.

Scholarships
Because of the generosity of our donors, camp scholarships are available. Families in need of
assistance should request a scholarship prior to attending camp. Contact the Office & Finance
Director at ext. 16 or email ghawaux@bgcridgefield.org for an application.

 5

Medical Policies and Procedures
The safety of campers is a top priority for the Boys & Girls Club summer camp program. Our
camp meets or exceeds all standards set by the Connecticut Licensing requirements.
The following medical procedures are in place to assure the appropriate support of summer
programs.
Medical Supervision
The Boys & Girls Club Summer Camp Physician is Dr. Rachel Rothschild. Dr. Rothschild is not
on-site during summer camp but provides oversight in our preparation for camp and is on-call
as needed for consultation.
Medical Training of Staff
All Directors and year-round professional staff are trained in CPR /AED (Automatic External
Defibrillator) for the Professional Rescuer and First Aid. They are also trained in the
administration of oral medications, topical medications, inhalants and epi-pens.
All Age Group Leaders, Counselors and Assistant Counselors are trained in CPR/AED and First
Aid.
Administration of Medications
Any child requiring the administration of medication (either daily or in emergency situations)
must have an Authorization for the Administration of Medication form (included in this packet)
on file. These forms (and medications) must be filed yearly and must be turned in before your
child’s first day of camp. Medications must be in the original container and labeled with the
child’s name, name of medication, directions for the medication’s administration, and date of
the prescription. All unused medication will be destroyed if not picked up within one week
following the camper’s departure at the end of camp. For more information, contact Kristin
Goncalves, Associate Executive Director, ext. 17. Medications will only be administered by
Directors or full-time year-round staff members.
Injuries Requiring Medical Attention
Adequate and appropriate supervision is provided at all times at the camp, however, accidents
and injuries can still occur.

In the event that an injury occurs during camp, staff (including volunteers) will attend to the
child. If the injury warrants further immediate medical attention, every effort will be made to
contact a parent or guardian. If efforts to contact parent/guardian are unsuccessful, the staff
will take steps to take the child to a physician, dentist or hospital. Please be sure to provide
complete contact information when registering your child for camp. If you are currently in the
online registration system please review your contact information and make sure that it is
accurate and complete. Please be sure to include appropriate daytime phone numbers.

Injuries that require minor treatment will be reported to a parent/guardian at the end of the
camp day.

 6

Behavior Management Policy
Behavior Skill Building
Camp provides a great opportunity for all children to develop skills and self-confidence. Our
camp behavior policy is intended to help all campers be their best while treating fellow
campers, staff and volunteers with respect.

Each day campers will be assigned to a camp group and will attend morning meeting to review
their schedule and their responsibilities. Campers must remain with their group or in areas
designated for their group while at camp and follow the direction of their counselors.

Zero Tolerance
We do not tolerate stealing, bullying, foul language, wandering from your group, or causing
physical harm to others. We reserve the right to remove your child from our camp program
without refund if these behaviors are identified and not corrected by your child.

Sit-out and Redirection
Techniques for handling disciplinary problems will be addressed by the Youth Development
Professional staff with the guidance of the Camp Director. A camper will sit out of an activity
and could have a loss of privileges as the first steps to manage behavior. They will then be
redirected to an activity that will positively channel the child’s energy. An apology by the
camper is expected immediately when problem behaviors occur.

Contacting Parents
The decision to contact a parent will be made once a determination has been made whether or
not the camper exhibited an effort to correct his/her behavior. Parents will be notified when a
camper has been warned about repeated offenses and will be given a final opportunity to
remain in camp. Continued inappropriate behavior will result in the dismissal from camp
without a refund.

 7

Camp Schedule and Hours
Daily Activities
The regular camp day begins at 8:00 am and runs through 5:00 pm. Extended day registration is
available from 5:00 pm – 6:00 pm daily.

Campers remain in low-structured, supervised activities until their morning meeting at 9:30 am.
This allows for the arrival of campers prior to the commencement of structured activities.

At 4:00 pm campers will transition to low structured activities in order to prepare them for
pick-up by parents by 5:00 pm. Extended day campers will remain in low-structured supervised
activities and/or swim time until pick-up by 6:00 pm.

2023 Summer Camp Sample Schedule
 8:00 am – 9:30 am Camp Arrival - low structured activities
 9:30 am – 9:45 am Group Meeting, Camp Assembly & announcements
 9:45 am – 10:30 am Swim Team/ Group activities
10:30 am – 11:15 am AM Swim Time
11:45 am – 12:15 pm Lunch
12:30 pm – 1:45 pm Group Activities
 1:45 pm – 2:45 pm PM swim time
 2:45 pm – 3:45 pm Snack & Group Activities
 4:00 pm – 5:00 pm Camp Departures- Low structured activities in village meeting areas
 5:00 pm – 6:00 pm Extended Day Activity Period & Departures

Field Trips
There are several offsite field trips offered over the course of the summer. Our field trips are
optional and the fees are in addition to the regular camp fees; field trip registration is done
separately through your online account on www.bgcridgefield.org. Registration for field trips
will open the Friday before the trip at 3:00 pm. For example, Week 2 field trips will open in the
online registration system at 3:00 pm on Friday of Week 1. A payment must be made in order to
reserve your child’s spot on the field trips. There are a limited number of spots and field trips
are booked on a first come, first serve basis.

 8

Aquatics
Safety is the number one priority of the staff on the pool deck at all times. All of our head
counselors, and all of our directors, are certified lifeguards.

Coverage on the Pool Deck
Lifeguards and a director are on the pool deck at all times during camp. The Age Group Leaders
and Counselors accompany their groups to their swim time. Many of our counselors are
cross-trained as lifeguards.

Swimming during the camp day
On regularly scheduled camp days, all groups have designated swim times in the morning
(approximately an hour) and the afternoon (approximately an hour and 15 minutes). Minis,
Group 1 and Group 2 swim together, and Groups 3 and 4 swim together.

As an extra precaution, our Mini and Group 1 members are only permitted to swim in the
shallow end of the pool, and are accompanied in the water by our Leaders-In-Training, as well
as our junior counselors.

Group 2b, 3 and 4 members can swim in the deep end of the pool after successfully passing our
Swim Assessment. Our swim assessment consists of being able to swim one length of the pool
without stopping, and being able to tread water in the middle of the pool for 30 seconds and
then successfully swimming back to the edge of the pool unassisted. The swim assessment is
administered by the Group Director, with the assistance of our Head Lifeguard. All campers
must take a Swim Assessment on their first day in the pool.

Personal Flotation Devices
We understand that many of our young members use Personal Flotation Devices (PFDs) as an
extra precaution, however, we only allow PFDs that are Coast Guard Approved. For more
information on PFDs please visit the United States Coast Guard website at
http://www.dco.uscg.mil/CG-ENG-4/PFD/

Personal items
We do not permit our members to bring their own water toys, including noodles, water guns,
diving rings or sticks, balls, and water baseball bats, as they are a distraction in the pool, and
often end up lost. Our staff works hard to come up with new activities and events on the pool
deck every day, ranging from Marco Polo to Cannonball contests.

Please remember to label your child’s swimming gear, particularly their goggles and towels. Our
lost and found pile at the pool deck grows larger and larger by the day!

 9

Camp Groups, Activities & Program Areas
The Boys & Girls Club summer camp program is a fun-filled extension of our year-round
programming. Campers participate in a wide range of activities both indoors and out. Campers
will have the opportunity to participate in swimming programs, arts & crafts, sports and
recreation all summer. Youth are encouraged to have fun while acquiring skills in physical,
personal and social development.

Camp Groupings
Campers are placed in groups by grade.
 Mini – entering 1st grade
 Group 1 – entering 2nd grade
 Group 2a – entering 3rd grade
 Group 2b – entering 4th grade
 Group 3 – entering 5th & 6th grade
 Group 4 – entering 7th & 8th grade

Program Areas
The facilities at the Boys & Girls Club of Ridgefield include a full size gymnasium, a heated
outdoor swimming pool, art room, indoor games room, soccer field, gaga pit, and a raised bed
garden.

Weekly Themes
Weekly themes make every week at camp different and exciting. Core activities like swimming,
sports, games, and art are always part of the camp schedule, but additional activities will be
added to match the theme of the week.

Week 1, June 26th to June 30th: Olympic Week
Week 2, July 3rd to July 7th: Foodmania (Club Closed 07/03, 07/04)
Week 3, July 10th to July 14th: Spirit Week
Week 4, July 17th to July 21st: Carnival Week
Week 5, July 24th to July 28th: Science Week
Week 6, July 31st to August 4th: Water Week
Week 7, August 7th to August 11th: All-Star Week
Week 8, August 14th to August 18th: Adventure Week

 10

Camp Activities

Daily Activities include but are not limited to: Art, Baggo, Basketball, Board Games, Capture the
Flag, Card games, Coke-n-Pepsi, Dodge ball, Dominoes, Flag Football, Four Square, Gaga Pit,
Kickball, Mat Ball, Nine Square, Soccer, Tug-o-War, Obstacle Course, Wiffle Ball, Relay Races,
Tag, Painting, Swimming, Knockout, Shuffle Board, Parachute, Playground Fun, Ultimate Frisbee,
and Volleyball.

Food & Refreshments
Bringing and Purchasing Food
Campers must bring lunch and snacks or purchase them from the Club daily. All groups will have
a designated morning and afternoon snack time in their daily schedule.

Lunch boxes will be stored in chilled coolers during the camp day. Campers’ lunch boxes should
include an ice pack and be labeled with their name.

Most parents understand their children’s eating habits better than we do. Please provide the
appropriate number of snacks, drinks and lunch to get them through a hot summer day.

Lunch Schedule
 Monday - Grilled Cheese
 Tuesday - Pizza
 Wednesday - Hot Dogs & Hamburgers
 Thursday - Pending Decision
 Friday - Mac & Cheese & Pasta

Snack Shack & Ice Cream Café
The Snack Shack will be open daily in the afternoon for children to purchase healthy snacks.
Snack Shack items range in price from $.25 to $1.00. You may choose to deposit money in your
child’s camp bank account to purchase snacks from the snack shack.

The Ice Cream Café is a great addition to camp. The Ice Cream Café will open Monday and
Wednesday afternoons. Ice Cream prices range from $1.00 to $3.00. Campers are not permitted
to borrow money from counselors or the Club to pay for ice cream.

In-Town Ice Cream & Candy Thursdays
We are excited to offer Ice Cream & Candy Thursdays this year, which will consist of a trip up to
town to visit Deborah Anne’s Ice Cream & Sweet Shop for those campers interested. Campers
who plan on attending Ice Cream & Candy Thursdays will let camp staff know at check in and
and escorted by camp staff following their lunch period on Thursdays.

 11

Technology Acceptable Use Policy
CLUB MEMBER USAGE
Before a member will be allowed to use Club technology equipment or their personal device, both the member and
his/her parent/guardian will need to read and sign the Technology Acceptable Use policy and return it to the Club.
Under the Technology Acceptable Use policy, the following relevant principles shall apply:
Club devices shall include any and all Club-owned existing and/or emerging technologies and devices that can take
photographs, play, and record audio or video, input text, upload and download content and/or media and transmit or
receive messages or images.
Personally owned devices shall include any and all member-owned existing and/or emerging technologies and devices
that can take photographs, play and record audio or video, input text, upload and download content and/or media and
transmit or receive messages or images.
Club purposes shall include program activities, career development, communication with experts and/or Club peer
members, homework, and Club activities. Members are expected to act responsibly and thoughtfully when using
technology resources. Members bear the burden of responsibility to inquire with staff when they are unsure of the
permissibility of a particular use of technology prior to engaging in its use.
Authorized use: Club devices and personally owned devices are permitted for use during approved Club times for Club
purposes and in approved locations only. The Club expressly prohibits the use of Club devices or personally owned
devices in locker rooms, restrooms, and other areas where there is an expectation of privacy.
Appropriate use: Members may not use any technology to harass, threaten, demean, humiliate, intimidate, embarrass,
or annoy their peers or others in their community. Any inappropriate use of a Club or personally owned device, as
determined by Club staff, can lead to disciplinary action including but not limited to confiscation of the device,
immediate suspension from the Club, termination of membership or other disciplinary actions determined to be
appropriate to the Club’s existing disciplinary policies including, if applicable, referral to local law enforcement.
Monitoring and inspection: Boys & Girls Club of Ridgefield reserves the right to monitor, inspect, copy, and review any
personally owned device that is brought to the Club. Parents/guardians will be notified before such an inspection takes
place and may be present, at their choice, during the inspection.
Parents/guardians may refuse to allow such inspections. If so, the member may be barred from bringing personally
owned devices to the Club in the future.
Loss and damage: Members are responsible for keeping devices with them at all times. Staff are not responsible for the
security and condition of the member’s personal device. Furthermore, the Club is not liable for the loss, damage,
misuse, or theft of any personally owned device brought to the Club.

Any inappropriate or unauthorized use of a Club or personally owned device, as determined by Club staff, can lead to
disciplinary action including but not limited to confiscation of the device, immediate suspension from the Club, termination
of membership or other disciplinary actions determined to be appropriate to the Club’s existing disciplinary policies,
including, if applicable, referral to local law enforcement.
Members must be aware of the appropriateness of communications when using Club or personally owned devices.
Inappropriate communication is prohibited in any public or private messages, as well as material posted online.
Inappropriate communication includes but is not limited to the following:

• Obscene, profane, lewd, vulgar, rude, inflammatory, threatening, or disrespectful language or images typed,
 posted, or spoken by members;
• Information that could cause damage to an individual or the Club community or create the danger of
 disruption of the Club environment;
• Personal attacks, including prejudicial or discriminatory attacks;
• Harassment (persistently acting in a manner that distresses or annoys another person) or stalking of others;

 12

Technology Acceptable Use Policy (Continued)
• Knowingly or recklessly posting false or defamatory information about a person or organization; or
• Communication that promotes the destruction of property, including the acquisition or creation of weapons or
 other destructive devices.

If a member is told to stop sending communications, that member must cease the activity immediately.
Cyberbullying: Members may not utilize any technology to harass, threaten, demean, humiliate, intimidate, embarrass,
or annoy their peers or others in their community. This behavior is cyberbullying, which is defined as bullying that takes
place using emerging technologies and devices. Any cyberbullying that is determined to disrupt the safety and/or well-
being of the Club, Club members, Club staff or community is subject to disciplinary action.
Examples of cyberbullying include, but are not limited to:

• Harassing, threatening or hurtful text messages, emails, or comments on social media.
• Rumors sent by email or posted on social networking sites.
• Embarrassing pictures, videos, websites, or fake profiles.

Members may not attempt to gain unauthorized access to the Club’s network, or to any other computer system through
the Club’s network. This includes attempting to log in through another person’s account or accessing another person’s
files. Members may not use the Club’s network to engage in any illegal act, including, but not limited to, arranging for
the purchase or sale of alcohol, tobacco, or other drugs; engaging in criminal activity; or threatening the safety of
another person. Members may not make deliberate attempts to disrupt the computer system or destroy data by
spreading computer viruses.

Monitoring and inspection: The Boys & Girls Club of Ridgefield reserves the right to monitor, inspect, copy, and review
files stored on Club-owned devices or networks. In addition, Boys & Girls Club of Ridgefield reserves the right to inspect
and/or review personally owned devices that are brought to the Club.

Parents/guardians will be notified before such an inspection takes place and may be present, at their choice, during the
inspection. Parents/guardians may refuse to allow such inspections, but the member may be barred from bringing
personally owned devices to the Club in the future.
Internet access: Personally owned devices used at the Club must access the internet via the Club’s content- filtered
wireless network and are not permitted to directly connect to the internet through a phone network or other content
service provider. Boys & Girls Clubs of Ridgefield reserves the right to monitor communication and internet traffic, and
to manage, open or close access to specific online websites, portals, networks, or other services. Members must follow
Club procedures to access the Club’s internet service.
Loss and damage: Members are responsible for keeping the personal device with them at all times. Staff are not
responsible for the security and/or condition of the member’s personal device. Furthermore, the Club shall not be liable
for the loss, damage, misuse, or theft of any personally owned device brought to the Club.
Parental notification and responsibility: While the Boys & Girls Clubs of Ridgefield Technology Acceptable Use Policy
restricts the access of inappropriate material, supervision of internet usage might not always be possible. Due to the
wide range of material available on the internet, some material might not fit the particular values of members and/or
their families. Because of this, it is not considered practical for the Boys & Girls Club of Ridgefield to monitor and
enforce a wide range of social values in student use of the internet. If parents/guardians do not want members to
access information beyond the scope of the Technology Acceptable Use Policy, they should instruct members not to
access such materials.
Digital citizenship: Club members shall conduct themselves online in a manner that is aligned with the Boys & Girls Club
of Ridgefield Code of Conduct. The same rules and guidelines members are expected to follow offline (i.e., in the real
world) shall also be followed when online. Should a member behave online in a manner

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Technology Acceptable Use Policy (Continued)
that violates the Boys & Girls Club of Ridgefield’s Code of Conduct, that member shall face the same discipline policy and
actions they would if their behavior had happened within the physical Club environment.
Club-owned-and-operated technology: Members are expected to follow the same rules and guidelines when using Club-
owned technology. Club technology and systems are the property of the Club, are intended to be used for Club purposes
and are to be used during approved times with appropriate supervision. Club members shall never access or use Club
technology or systems without prior approval.
Digital citizenship and technology safety training: All members who wish to use a Boys & Girls Clubs device or
equipment will be required to successfully complete a BGCA-provided digital citizenship and technology safety training.
This training is required for all members annually.

 14

Contact Information
Camp Cell Phone
203-501-6051
Please store this cell phone number in a safe place! A camp director will always answer this
phone or return any missed calls or messages within 30 minutes. During the Camp Day there
will not be a staff member at the front desk however, we will check the general mailbox at
203-438-8821 ext. 10 several times a day should you need to leave a non-urgent message for
your child(ren) or for the camp directors regarding your child(ren).

BGCR Management Team
Mike Flynn, Chief Executive Director: 203-438-8821 ext. 15, mflynn@bgcridgefield.org
Kristin Goncalves, Associate Executive Director: 203-438-8821 ext.17,
kgoncalves@bgcridgefield.org
Gerry Hawaux, Office & Finance Manager: 203-438-8821 ext. 16, ghawaux@bgcridgefield.org
Jeff Goncalves, Senior Program Director: 203-438-8821 ext. 19, jgoncalves@bgcridgefield.org
Devon Lawrence, Program Director: 203-438-8821 ext. 13, dlawrence@bgcridgefield.org
Tim Cozens, Program Manager: 203-438-8821 ext. 14, tcozens@bgcridgefield.org
Dan Liddi, Program & Community Outreach Manager: 203-438-8821 ext. 12,
dliddi@bgcridgefield.org
Fanery Orejuela, Program Coordinator: 203-438-8821 ext. 11, forejuela@bgcridgefield.org

Program Staff:
Triston Philip, Program Coordinator: tphilip@bgcridgefield.org
Joe Haskins, Program Coordinator: jhaskins@bgcridgefield.org

Camper Required Forms
All campers will be required to have the following paperwork on file before they can start camp:
● An up-to-date physical form (valid for 3 years - must be dated after 08/19/2020)
● Authorization to Administer Medication (if they require daily medication or medication in case
of emergencies)
● BGCR Camp Permission Slip/Sunscreen Form/General Waiver
● Credit Card Authorization Form (if you have an open balance)
● Office of Early Childhood & Boys & Girls Club of America’s COVID-19 Waiver Form
● Parent/Camper Handbook Agreement
All forms MUST be turned in no later than Wednesday, June 14th. Forms can be emailed to
Fanery Orejuela, at forejuela@bgcridgefield.org. You can also fax them to the Club at
203-438-0676. If you need to drop off the forms our hours are from 10am-6:30pm
Monday-Friday. All forms can be found on our website: www.bgcridgefield.org or by contacting
one of our staff members.

 15

YOUTH CAMP HEALTH EXAM/RECORD
 FOR CAMPERS AND STAFF
 Physical Exams Are Valid For 3 Years
 From Date of Last Examination

 Camper Please Return Completed Form to the Camp
 Staff
Name_____________________________________________ Date of Birth Phone
Guardian Address
Emergency Contact Telephone
Date of Arrival at Camp: _________________________________ Departure Date: ______________________________________________
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

 TO BE COMPLETED BY THE HEALTH CARE PROVIDER

 Date of Exam ____/____/____
May participate in all camp activities YES NO
May participate except for: ____________________________________________________________________________________

Does the individual have any known medical or emotional illness or disorder that poses a risk to other children or which affects the
individual’s functional ability to participate safely in a youth camp? YES NO
If yes, please explain _________________________________________________________________________________________
___________________________________________________________________________________________________________

Are there any prescription or over the counter medication(s) this individual needs to take while at camp? YES NO
If yes, indicate names of medication(s):___________________________________________________________________________
NOTE: A written authorization and parent permission for the administration of medication at camp are required.

Does the individual have any disabilities or special health care needs such as allergies, special dietary needs? YES NO
If yes, please explain _________________________________________________________________________________________
___________________________________________________________________________________________________________
NOTE: If the camper has a special health care need or disability that requires special care be taken or provided during the time the individual is at camp, an
individual plan of care shall be developed with the parent and health care provider and updated as necessary. The plan shall include appropriate care of the
camper in the event of a medical or other emergency and signed by the parent and staff responsible for the care of the camper.

If camper/staff is school aged or younger, have they been immunized in accordance with the schedule adopted by the Commissioner of
Public Health pursuant to section 19a-7f of the Connecticut General Statutes? YES NO

Additional Comments:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Printed Name of Health Care Provider: ___________________________________________________________________________

Address: ________________________________________________________________ Phone: ____________________________

Signature of Physician, PA, APRN or RN ______________________________________ Date Form Signed: __________________

Authorization for the Administration of Medication

Sunscreen Application and Off-Site Permission Form
Parent / Camper Agreement
The______________________ family has reviewed the information stated throughout the Summer Camp Packet. By
signing this agreement, we understand the policies and procedures that are in place at the Boys & Girls Club of Ridgefield
Summer Camp. I have discussed and reviewed the packet with my child(ren) and our family is excited to attend the Boys
& Girls Club Summer Camp.

Scheduled Field Trip, Off-site locations and Transportation
I, the parent/guardian of the child(ren) listed below, understand that the scheduled field trips or off-campus activities
occur during summer camp at locations specified in field trip announcements. Scheduled field trips will leave the Club at
approximately 9:00 am and will arrive back at the Club at approximately 4:00 pm. I understand that on Thursdays
campers will walk to town with camp staff for lunch. I also understand that campers will use the Veteran Park Fields
which are not part of the Boys & Girls Club campus. Occasionally, there may be opportunities to participate in activities
within walking distance of the Club without making plans ahead of time.

I understand transportation to the field trip location will be by walking, or via transportation in the Boys & Girls Club bus,
school bus, or coach bus.

Release Statement
I hereby grant permission for my son/daughter to participate in field trips and off-site activities. I understand that
adequate and appropriate supervision will be provided. I recognize, however, that unanticipated situations and problems
can arise on any trip. I further agree to release and hold harmless the Boys & Girls Club of Ridgefield, its agents, officers,
and volunteers, from any and all liability, claims, suits, demands, judgments, costs, interests, and expenses (including
attorneys’ fees) arising from such activities including any accident or injury to the child and the medical costs.

In the event of an injury requiring medical attention, I hereby grant permission to the supervising staff (including
volunteers) to attend to my child. If the injury warrants further medical attention, I expect every effort will be made to
contact me to receive authorization before action is taken. If efforts to contact me are unsuccessful, I grant permission
for necessary medical treatment to be given to my child. In addition, I hereby give permission to the staff (including
volunteers) to take my child to the physician, dentist, or to the hospital if an accident or serious illness occurs on the trip
and I cannot be located. In the event that a student must return to the Club independently for reasons of health,
accident, failure to conform to rules established by the staff member in charge, etc., I agree to accept full responsibility
for and pay for the cost of medical care, transportation and other incidental expenses.

Application of Sunscreen I am completing the Sunscreen Opt-out form.
I give permission for the Camp Group Leader or other designated Boys & Girls Club staff member to assist my child with
his/her application of sunscreen to exposed skin, including but not limited to the face, tops of ears, neck, shoulders,
arms, legs and feet. I understand that the application of sunscreen will take place twice daily. Sunscreen will not be
applied to any broken or irritated skin. I will be notified if my child develops a skin reaction. If I do not want sunscreen
applied to my child I must submit the Sunscreen Opt-out form on page 20 of the Summer Camp Packet.
It is my responsibility to provide sunscreen with a SPF of 15 or higher. In the event that my child does not have sunscreen
with him/her, the camp may apply Rocky Mountain SPF 30 Broad Spectrum Sunscreen. I have reviewed the active
ingredients listed on the Opt-out form and am not aware that my child is allergic to these ingredients.

Child’s #1 Name: (Print) __________________________________________________
Child’s #2 Name: (Print) __________________________________________________
Child’s #3 Name: (Print) __________________________________________________
Parent/Guardian: (Print) __________________________________________________
Parent/Guardian Signature ________________________________________________
Home Ph: ___________________ Cell Ph: ___________________ Work Ph: __________________

 18

Sunscreen Opt-out Form
I do not give permission for the Camp Group Leader or other designated Boys & Girls Club staff
member to assist my child with his/her application of sunscreen to exposed skin, including but
not limited to the face, tops of ears, neck, shoulders, arms, legs and feet.

It is my responsibility to provide sunscreen with a SPF of 15 or higher. I have reviewed the
active ingredients listed below and my child may NOT use any sunscreen other than the one
that he/she brings to camp. (Sunscreen bottle must be labeled with child’s first and last name in
permanent ink).

Date signed: _______________ (Good from June 25 to August 19, 2023 only)

Name of camper(s): _____________________________________

Parent/Guardian Signature: _____________________________________

Rocky Mountain Sunscreen
SPF 30 Broad Spectrum
Hypoallergenic and Fragrance Free

Ingredient Listing
Active Ingredients:
Avobenzone 3.0%
Homosalate 10.0%
Octisalate 5.0%
Octinoxate 7.5%
Oxybenzone 4.0%

Inactive Ingredients: Acrylates/C10-30 Alkyl Acrylate Crosspolymer, Aloe Barbadensis Leaf Juice,
Benzyl Alcohol, Carbomer, Cetyl Alcohol, DEA-Cetyl Phosphate, Disodium EDTA, Hydrogenated
Polyisobutene, Stearic Acid, Triethanolamine, Water

 19

Credit Card Authorization Form
 All information will remain confidential.

Cardholder Name (as printed on card):

 ___________________________________________
Billing Address (for credit card below):

 ___________________________________________

 ___________________________________________

Credit Card Type: _____ Visa _____ MasterCard _____ Amex

Credit Card Number: ___________________________________________

Expiration Date: ___________________________________________

Card Identification Number (4 digits located on front of Amex; 3 digits located on back of Visa
and MasterCard): ________

I authorize the Boys & Girls Club of Ridgefield to charge any unpaid balance for Summer
Camp 2023 to my credit card provided above (on or after September 1, 2023). This form
may also be used for telephone orders such as snack shack or membership fees.

Cardholder – Print Name, Sign and Date Below:

Signed: ___________________________________________

Dated: ___________________________________________

Printed Name: ___________________________________________

Child’s Name(s) ___________________________________________

Telephone number(s) __________________________________________

 41 Governor Street, Ridgefield, CT 06877
 Tel (203) 438-8821 Fax (203) 438-0676 Web www.bgcridgefield.org

 20

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization.
COVID-19 is extremely contagious and has significant person-to-person spread. As a result, federal, state, and local
governments and federal and state health agencies have recommended social distancing measures and have, in
many locations, required ongoing prohibitions on the congregation of groups of people of various sizes.

Boys & Girls Club of Ridgefield (“The Club”) has put in place preventative measures to reduce the spread of
COVID-19. These include, but are not limited to, decreased group sizes, social distancing, wellness monitoring,
increased sterilization and cleaning, and required hand-washing. However, the Club cannot guarantee that you or
your child(ren) will not become infected with COVID-19 by attending. Further, attending the Club could increase
your risk and your child(ren)’s risk of contracting COVID-19.

By signing this agreement, I hereby attest that I have been informed that people who are 65 years and older and
people of any age who have serious underlying medical conditions or are at higher risk for severe illness from
COVID-19 are recommended to stay at home. A list of medical conditions associated with a higher risk for severe
illness from COVID-19 can be found on the CDC’s website. Individuals and families should consult their healthcare
provider to determine whether they have medical conditions that place them at risk. I also attest that I have been
informed that children living in households with individuals who are 65 years and older OR have higher risk for
severe illness from COVID-19 are recommended to stay home.

I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be
exposed to or infected by COVID-19 by attending the Club and that such exposure or infection may result in
personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or
infected by COVID-19 at the Club may result from the actions, omissions, or negligence of myself and others,
including, but not limited to, Club employees, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren)
or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability,
or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s
attendance at the Club or participation in Club programming (“Claims”). On my behalf, and on behalf of my
children, I hereby release, covenant not to sue, discharge, and hold harmless the Club, its employees, agents, and
representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any
kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the
actions, omissions, or negligence of the Club, its employees, agents, and representatives, whether a COVID-19
infection occurs before, during, or after participation in any Club program.

Signature of Parent/Guardian ______________ Date ___________________

Name of Parent/Guardian ______________

Name of Club Member(s)_____________________________________________

 21

Boys & Girls Club Parent/Guardian/Member Agreement Contract
 Please sign and return to the Boys & Girls Club

The______________________________ family has reviewed the informa on stated throughout the
Boys & Girls Club of Ridgefield’s Parent & Club Member Handbook, including the Club’s Policies on
Protec on of Youth (Child & Club Safety) and the Club’s Acceptable Technology Use Policy.

As a family, we have discussed and reviewed all the policies. By signing this agreement, we
understand and agree to all the policies and procedures outlined. We understand that viola on of any
of these policies will result in removal/dismissal from the Club’s programs without a refund.

Child’s #1 Name: (Print) __________________________________________________

Child’s #2 Name: (Print) __________________________________________________

Child’s #3 Name: (Print) __________________________________________________

Child’s #4 Name: (Print) __________________________________________________

Child’s #5 Name: (Print) __________________________________________________

Parent/Guardian: (Print) __________________________________________________

Parent/Guardian Signature ________________________________________________

 22 Updated: September 1, 2022