Step 1 of 7 0% Once you complete and submit the online registration, you will receive a confirmation email within 48 hours. If your selected weeks are unavailable, you will be notified. If you require assistance, please contact our office at 610.489.2191. To complete the registration, you will need general information about your camper, a credit card for the deposit and your medical insurance information. Families may cancel up to TWO registered weeks from their original registration without penalty, allowing for some flexibility to families who may have a slight change in summer plans. Canceling more than two weeks from the original registration will incur a fee of $100 for every week that is canceled outright (after two weeks). As always, there is no penalty for the changing of weeks. Families are welcome to switch registered weeks to other weeks in the summer without penalty, assuming desired weeks are available.CAMPER INFORMATIONPlease fill in the camper's information.Camper First Name* Camper Last Name* Camper Gender* Male Female Age as of 7/1/2024*Our youngest campers must be 5 years of age by May 1st to attend.Date of Birth* MM slash DD slash YYYY Grade Completed (2024)*Pre-schoolKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th GradeSchool Attending* Camper T-Shirt*Every camper gets a FREE Hideaway Day Camp T-shirt. Please indicate your camper's size.Youth SYouth MYouth LAdult SAdult MAdult LIf possible, please group my camper with: Mailing Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code YOUR INFORMATIONPlease fill in the parent or guardian information.Primary Parent or Guardian Name* Relationship to Camper* Primary Phone*Secondary PhoneSecondary parent, guardian or emergency contact* Relationship to Camper (secondary) Primary Phone*Secondary PhoneEmail*Used for correspondence My child lives with both parents* Yes No If No, my child lives with:* RATES1 - 3 weeks: $550/week (NO transportation) The following prices include transportation: 4 weeks: $550/week 5 weeks: $540/week 6 weeks: $530/week 7 weeks: $520/week 8 weeks: $510/week Weekly Sibling Discounts: Second Camper $15 discount, Third Camper $20 discount, Fourth Camper $25 discount *Fourth of July Week Discount: $50ENROLLMENTYou may cancel up to two weeks from this registration. Canceling more than two weeks will incur a fee of $100 for every week that is canceled outright, beginning with the third week canceled. Please select your weeks carefully.CAMPER WEEKS:*Choose 1-8 weeks. Weeks do not need to be consecutive. A 4-week minimum is required for bus transportation (central location/bus stop only) and you will be notified if your transportation address is not within our serving area. Please select ALL weeks that apply: June 17 June 24 July 1* (Closed 7/4, $50 discount) July 8 July 15 July 22 July 29 August 5 PIZZA ORDEREvery Monday is Pizza Monday! Campers may sign up to receive two slices of pizza, a choice of snack, and Gatorade for each Monday that they are attending.Would you like to participate in Pizza Mondays?*Cost is $5 per week. Yes No TRANSPORTATION INFORMATIONTransportation*Transportation is provided by school bus at a CENTRAL LOCATION. You will be notified of the location of your bus stop two weeks prior to the start of your camper's stay. If you would like transportation, a 4-week minimum enrollment is required. If you will be providing your own transportation, there is a $25/week/camper discount if the camper is enrolled for 4 weeks or more. Would you like us to provide bus transportation, or will you provide your own? Bus Own If you have chosen Hideaway to provide transportation for your camper(s), please choose one of the following: Both AM and PM AM Only PM Only Address for Transportation Pick-up and/or Drop-off:Transportation by camp van/bus will be at a CENTRAL LOCATION (close to your home, business address or other location). The following address will help us to determine that location which you will be notified of prior to the start of your camper's season. Transportation same as mailing address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code If the above address is a Business address, please enter the name of the business. Closest street intersection or development name: ADDITIONAL PICK-UP LISTAdditional Pick-Up Information:Please list anyone other than parents/guardians who are permitted to pick up your camper(s). Please also list the person's relationship to the camper(s), eg. family friend, aunt, babysitter, etc. HIDEAWAY DAY CAMP POLICIESTERMS AND CONDITIONS*HDC has a rolling enrollment. Enrollment, though limited, extends throughout our summer season. Campers are accepted on a first-come, first-serve basis. We cannot hold placement for any camper without a completed registration and deposit. Should your registration be received after the groups reach capacity, you will be notified, and placed on a waiting list and your deposit returned. Full payment is required before we will add weeks/extend your camper's stay after the camp season has begun. The Camp is not responsible for the camper's equipment or personal belongings, while in transit or at camp, if lost or damaged by fire, theft, or otherwise. The Camp will make every effort to provide proper supervision so that losses will be at a minimum. Final group and transportation arrangements will be made when all tuitions are paid in full. Hideaway reserves the right to deny bus transportation due to the pickup/drop off location of camper. Please call our office to check the availability of transportation in your area before sending in your completed registration. Camp pledges to transport all children in the safest, most efficient way possible. I Agree CANCELATION/REFUND POLICY* If a cancelation occurs in writing before March 1st all monies, including deposit, shall be returned. If a cancelation occurs after March 1st and before April 1st, all monies except the original deposit ($300) shall be returned. FULL PAYMENT IS DUE APRIL 1st NO REIMBURSEMENTS WILL BE MADE for any canceled weeks after April 1st. There is no allowance nor refund for any absences, late arrival or early withdrawal of campers. This is STRICTLY enforced. Families may cancel up to TWO registered weeks from their original registration without penalty, allowing for some flexibility to families who may have a slight change in summer plans. Canceling more than two weeks from the original registration will incur a fee of $100 for every week that is canceled outright (after two weeks). We understand that plans do change and unforeseen circumstances arise but this is necessary in order to prevent families from registering for multiple weeks, only to cancel the majority. Doing so prematurely closes our groups, preventing other families from being able to register. We kindly ask that you please check your summer schedules prior to registering your campers as a courtesy to HDC and other camp families who are trying to plan their summers as well. As always, there is no penalty for the changing of weeks. Families are welcome to switch registered weeks to other weeks in the summer without penalty, assuming desired weeks are available. I Agree RELEASE OF CLAIMS & MEDICAL AUTHORIZATION*Medical and insurance information is collected at the time of registration. Parent or guardian agrees that the information shared with HDC is believed to be true and accurate to the best of your knowledge and that your camper is in sound physical and mental health and fully able to participate in all camp activities without the need of individual or specialized attention, medical or otherwise. We reserve the right to deny or cancel enrollment if the camper's health, physical or mental, interferes with any camp activity or is not in the best interest of the camp or the other campers. The Directors reserve the right to deny, cancel, sever or suspend a child's enrollment if deemed his/her behavior is not in the best interest of the camper or the Camp. Fees not refundable. As the parent or guardian of a camper, intending to be legally bound, do hereby, for myself, my heirs, executors, and administrators, waive and release Hideaway Day Camp, their officers, representative, successor, and/or assigns for any and all damages which may be sustained or suffered by me in connection with my association with the HDC program, or any activities related thereto, including without limitation, my traveling to or participating in and returning from any activity associated with the program. I grant HDC permission to act on my behalf in safeguarding my camper(s) health and safety. In the event that I cannot be contacted in an emergency, I grant Hideaway Day Camp permission to give my child immediate treatment and/or take my child to a hospital emergency room. I agree that Hideaway Day Camp is not responsible for accidents, injuries, and/or medical or dental expenses arising from my child's participation and covenant not to sue and waive, release, and discharge Hideaway and anyone working on their behalf from any and all claims of liability or any expenses. I Agree PHOTO AND VIDEO RELEASE*I grant permission for my child or ward to be photographed, videotaped and/or interviewed during the course of our season by HDC or any of its authorized agents, and consent for the publication, broadcast, or other use of the camper’s images and/or words for the purposes of promoting Hideaway Day Camp. In addition, I, intending to be legally bound for myself, my heirs, executors and administrators, release Hideaway Day Camp, or any parties acting on their behalf and with their approval, from liability for such uses of my child’s or ward’s images and/or words. I Agree HANDBOOK AFFIRMATION*I will read the Camper Handbook to understand what is expected of me as a member of Hideaway Day Camp. I understand and will discuss with my child(ren) that s/he will be expected to conduct her/himself in a disciplined manner while enrolled in camp. The Camper Handbook will be made available upon registration. I Agree Health HistoryParent/Guardian Authorization for Health Care*I, as the parent/guardian, agree that the following health history information is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status. Yes No Medical Insurance Information*This camper is covered by family medical/hospital insurance. Yes No Insurance Company* Policy Number* Subscriber* Insurance Company Phone Number*Allergies*This camper is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other No known allergies Please describe the camper's allergy*Diet, Nutrition* This camper eats a regular diet This camper eats a regular vegetarian diet This camper has special food needs (Please describe below) Special Food Needs*Restrictions* I have reviewed the program and activities of the camp and feel the camper can participate without restrictions. I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations. (Please describe below.) Restrictions or adaptations*1. Ever been hospitalized?* Yes No 2. Ever had surgery?* Yes No 3. Have recurrent/chronic illnesses?* Yes No 4. Had a recent infectious disease?* Yes No 5. Had a recent injury?* Yes No 6. Had asthma/wheezing/shortness of breath?* Yes No 7. Have diabetes?* Yes No 8. Had seizures?* Yes No 9. Had headaches?* Yes No 10. Wear glasses, contacts, or protective eyewear?* Yes No 11. Had fainting or dizziness?* Yes No 12. Passed out/had chest pain during exercise?* Yes No 13. Had mononucleosis ("mono") during the past 12 months?* Yes No 14. If female, have problems with periods/menstruation?* Yes No 15. Have problems with falling asleep/sleepwalking?* Yes No 16. Ever had back/joint problems?* Yes No 17. Have a history of bedwetting?* Yes No 18. Have problems with diarrhea/constipation?* Yes No 19. Have any skin problems?* Yes No 20. Traveled outside the country in the past 9 months?* Yes No Please explain “Yes” answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and dates of travel.*Please explain “Yes” answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and dates of travel. Mental, Emotional, and Social Health1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?* Yes No 2. Ever been treated for emotional or behavioral difficulties or an eating disorder?* Yes No 3. During the past 12 months, seen a professional to address mental/emotional health concerns?* Yes No 4. Had a significant life event that continues to affect the camper’s life?* Yes No 5. History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others* Yes No Please explain “Yes” answers in the space below, noting the number of the questions. The camp may contact you for additional information.*Medication at Home*Are there any medications that the camper will be taking at home during camp? "Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Yes No Name of medication* Reason for taking it* Medication at Camp*"Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. HDC requires original pharmacy containers with labels which show the camper’s name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp. This camper will not take any daily medications while attending camp This camper will take the daily medication(s) while at camp: Name of medication* Reason for taking it* When it is given?* Amount or dose given* How it is given?* What Have We Forgotten to Ask?Please provide in the space below any additional information about the camper’s health that you think important or that may affect the camper’s ability to fully participate in the camp program.Upload a copy of your insurance cardMax. file size: 256 MB. PAYMENTA $300 deposit is required to complete registration. Once your online application is processed by the office, you will receive a confirmation email. All balances are due April 1st. If applying after April 1st, balance is due once registration confirmation is received. No refunds or reimbursements after April 1st. If enrollment is canceled after March 1st and before April 1st, all monies except the $300 deposit is returned.Deposit* Price: Credit Card* Billing Address* Same as Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands NameThis field is for validation purposes and should be left unchanged.