2012 Camp Kiwi Online Registration Form

Online Registration requires a $600 deposit at the time of registration. The balance must be paid by check by May 1, 2012.

For information on Camp Kiwi or tuition rates referrenced in this form please contact the main office at 845-277-3876 or email info@campkiwi.com.

Camp Kiwi Mailing Address:
P.O. Box 435
Mahopac, NY 10541

Camper Information

* Is this application for a returning camper?

Yes

No

Gender

* Child's First Name:

* Child's Last Name:

* Date of Birth:

* Street Address:

* City:

* State:

* Zip:

* Home Phone:

* Parent's Business Phone:

* Name of School:

Grade Entering 2012:

* What will your campers age be on the first day of camp?

Parent Information:

Mother's Full Name:

Father's Full Name:

Mother's Occupation:

Father's Occupation:

Mother's Business Phone:

Father's Business Phone:

Mother's Cell Phone:

Father's Cell Phone:

* Email Address:

* Is there is a written agreement and/or court order pertaining to custody?

Yes

No

* Please select the primary custody:

Please attach a copy of the written legal agreement or court order pertaining to custody:

Please enter the name(s) and relationship of any individual that is authorized to pick your child up from camp:

Medical & Emergency Release Information:

* Doctor's Name:

* Doctor's Phone Number:

Please ensure you complete the Camp Kiwi Medical Form available on our website.

* Please advise of any history of medical conditions or surgical procedures, therapy programs and/or regularly-taken prescription medications or special needs: PLEASE BE SPECIFIC

EMERGENCY TREATMENT RELEASE
(Required By the New York State Camping Law)

* Camper's Name:

In the event that I cannot be reached in case of emergency affecting my child at camp or going to and from camp, I hereby give permission to my physician as listed in the camp record, or if unavailable, the physician selected by the camp director to administer proper treatment to my child as named above.

* Please enter your initials affirming you agree with the above statement:

* Date:

In the event we cannot reach you if your child is ill, please write in the name and phone number of a relative or friend whom we may contact.

* Additional Emergency Contact Name:

* Additional Emergency Contact Phone Number:

Additional Emergency Contact Name:

Additional Emergency Contact Phone Number:

Additional Information:

* Does your child have permission to leave the Kiwi campus for inter-camp sporting events?

Yes

No

Would your child like to be in the same group as a friend? If so please enter the campers name here:

How did you become interested in Camp Kiwi?

Program Selection & Tuition:

* Is your camper a CIT? (Ages 14-15)

* Please Select:

Full Camp (5 days a week)

Mini-Camp for 3-13 year olds (3 days a week)

Mini-Camp for 3-7 year olds (2 days a week)

2 Year Olds (5 days a week, 9:00am-12:30pm)

* Please select the amount of weeks your camper will be attending (Only a deposit is required at this time):

Enrollment: 4 Weeks: $3,310.00

Enrollment: 5 Weeks: $3,510.00

Enrollment: 6 Weeks: $3,760.00

Enrollment: 7 Weeks: $4,010.00

Enrollment: 8 Weeks: $4,260.00

* Please select the amount of weeks your CIT Camper will be attending (Only a deposit is required at this time):

Enrollment 4 Weeks: $2,118.00

Enrollment 5 Weeks: $2,246.00

Enrollment 6 Weeks: $2,406.00

Enrollment 7 Weeks: $2,566.00

Enrollment 8 Weeks: $2,726.00

* Please select the amount of weeks your camper will be attending 3 day mini-camp for 3-13 year olds (Only a deposit is required at this time):

Enrollment 4 Weeks: $2,185.00

Enrollment 5 Weeks: $2,317.00

Enrollment 6 Weeks: $2,482.00

Enrollment 7 Weeks: $2,647.00

Enrollment 8 Weeks: $2,812.00

* Please select the amount of weeks your camper will be attending 2 day mini-camp for 3-7 year olds (Only a deposit is required at this time):

Enrollment: 4 Weeks: $1,655.00

Enrollment: 5 Weeks: $1,755.00

Enrollment: 6 Weeks: $1,880.00

Enrollment: 7 Weeks: $2,005.00

Enrollment: 8 Weeks: $2,130.00

Please select the days of the week your camper will be attending 2 day mini-camp:

Please select the days of the week your camper will be attending 3 day mini-camp:

* Please select the amount of weeks your camper will be attending our 2 year old program (Only a deposit is required at this time):

Enrollment: 4 Weeks: $1,374.00

Enrollment: 5 Weeks: $1,454.00

Enrollment: 6 Weeks: $1,554.00

Enrollment: 7 Weeks: $1,654.00

Enrollment: 8 Weeks: $1,754.00

* Check the weeks your camper is attending:

CAMP SHIRT
(A camp t-shirt is included in the enrollment cost)

* Shirt Size:

Lunch:

If you would like to add Kiwi Lunch, please select the appropriate box (Payment is not required at this time):

If you would like to add Kiwi Lunch for 3 day enrollment, please select the appropriate box (Payment is not required at this time):

If you would like to add Kiwi Lunch for 2 day enrollment, please select the appropriate box (Payment is not required at this time):

Lunch is not available for the 2-Year Old Program.

Transportation:

Please complete this section if you require transportation to and from Camp Kiwi for your child. Kiwi offers 3 transportation packages for your convenience:

-Door-to-Door Pick-Up and Drop-Off
-Metro North #1: Valhalla, Mt. Pleasant, Hawthorne, Pleasantville, Chappaqua.
-Metro North #2: Mt. Kisco, Bedford Hills, Katonah, Goldens Bridge.

Transportation payment is not required at this time, you will be billed separately.

Transportation type:

No Transportation

Door-to-Door

Metro North #1

Metro North #2

* Please provide the street address and any cross streets for the door-to-door transportation location:

* Please select the total weeks door-to-door transportation is required:

Transportation (Door-to-Door) 4 Weeks: $600 / $480 (discount 2+ campers same address)

Transportation (Door-to-Door) 5 Weeks: $650 / $530 (discount 2+ campers same address)

Transportation (Door-to-Door) 6 Weeks: $700 / $580 (discount 2+ campers same address)

Transportation (Door-to-Door) 7 Weeks: $750 / $630 (discount 2+ campers same address)

Transportation (Door-to-Door) 8 Weeks: $800 / $680 (discount 2+ campers same address)

* Please select the station stop for Metro North 1:

* Please select the total weeks Metro North 1 transportation is required:

Transportation (Metro North 1) 4 Weeks: $300.00

Transportation (Metro North 1) 5 Weeks: $325.00

Transportation (Metro North 1) 6 Weeks: $350.00

Transportation (Metro North 1) 7 Weeks: $375.00

Transportation (Metro North 1) 8 Weeks: $400.00

* Please select the station stop for Metro North 2:

* Please select the total weeks Metro North 2 transportation is required:

Transportation (Metro North 2) 4 Weeks: $250.00

Transportation (Metro North 2) 5 Weeks: $275.00

Transportation (Metro North 2) 6 Weeks: $300.00

Transportation (Metro North 2) 7 Weeks: $325.00

Transportation (Metro North 2) 8 Weeks: $350.00

Conditions of Registration:

Parent warrants and represents the camper is in sound physical and mental health and fully able to participate in all camp activities without need of individual or specialized attention or medical regimen and that camper’s health will not impinge or impact negatively on other campers or the camp program. This includes any allergies, physical conditions, mobility issues, etc., which may require special attention and, if so, please attach a separate sheet of paper and specify the nature of such condition and the necessary treatment or accommodations. Parent further agrees to advise camp promptly of any change in the camper’s physical or mental health between the date of enrollment and the start of the camp season.

“I understand that part of the camping experience involves activities and group living arrangements and interactions that may be new to my child, and that they come with certain risks and uncertainties beyond what my child may be used to dealing with at home. I am aware of these risks, and I am assuming them on behalf of my child. I realize that no environment is risk-free, and so I have instructed my child on the importance of abiding by the camp’s rules, and my child and I both agree that he or she is familiar with these
rules and will obey them.”

It is required by Camp Kiwi, that a child enrolled with special needs, have an individual staff person, at all times. It is also required by Camp Kiwi, that the parents/guardians of the special needs child, provide to the camp this individual Staff Person. This person must attend Camp Kiwi's Staff Orientation, and be presented to the Owners/Directors before orientation begins (before June 1).

Camp Kiwi will make all decisions regarding camper’s fitness to participate in particular activities or the entire camp program.

At any time before opening day or during the camp season Camp Kiwi retains the right to cancel this contract if it determines that the physical, mental, medical or emotional condition of the child would prevent him/her from participating safely and satisfactorily in our program or interacting positively with other campers. Also, once Camp Kiwi is in session, Kiwi can initiate the cancellation of this contract and the dismissal of the child if the child exhibits unacceptable behavior which prevents our staff from safely supervising him/her or proves detrimental to himself/herself, other campers or staff members as determined by Camp Kiwi directors.
The parent who signs this registration form represents that he/she has full authority to do so and will be responsible for payment of the camp fees. No refund will be made for early withdrawal of the child before the end of the camp season. The parent has reviewed the withdrawal policy on the attached addendum.
“It is agreed that any dispute or cause of action arising between the parties, whether out of this agreement or otherwise, can only be brought in a court of competent jurisdiction located in Putnam County, N.Y., and shall be construed in accordance with the laws of New York.” If contracted, regular daily transportation is provided to and from your child’s home or as reasonably close to it as the bus can be routed. Requests for occasional changes will be honored only if a seat is available on the bus that is routed closest to the different location and the change in route does not unduly inconvenience its regular route. Transportation may not be available to certain areas.

Camp Kiwi will release your child to either parent (or persons authorized by same) on our site at any time during the day if parental arrangements for pick up have been made beforehand with the camp office. If both parents do not live at the same address, the above procedure will apply unless restricted by a court order. Absent same, disputes between parents must be resolved immediately or Camp Kiwi reserves the right to terminate this contract and dismiss the child. Should this action be required, no refund will be made.

The parent irrevocably authorizes and consents to the Camp’s use of the child’s name, photograph, portrait or image in connection with the Camp’s brochure or other promotional or advertising publications and to the Camp’s use of a child’s and/or child’s family’s home address and phone number for group and car pool lists.

The parents release the Camp and shall indemnify and hold the Camp harmless from and against any and all claims, liabilities and expenses (including reasonable attorney’s fees arising from such use).

* By entering your initials in the box below you are stating that you have read and agree to the above conditions and have filled in the required information required for enrollment to Camp Kiwi.

* Indicates Response Required

Week 1= June 25 - June 29	Week 2= July 2 - July 6
Week 3= July 9 - July 13	Week 4= July 16 - July 20
Week 5= July 23 - July 27	Week 6= July 30 - August 3
Week 7= August 6 - August 10	Week 8= August 13 - August 17

Youth X-Small	Youth Small	Youth Medium	Youth Large	Youth X-Large
Adult Small	Adult Medium	Adult Large	Adult X-Large	Adult XX-Large