2022 Application for New Camper/CIT/Counselor/RA


Camper/CIT/Counselor/RA Information
   
*English Last Name:
*English First Name:
Last Name in Chinese(Chinese chars please):
First Name in Chinese(Chinese chars please):
*Gender:
Male
Female
*School Grade (number only, in 2022 Fall semester):
*Birthday (format yyyy-mm-dd; e.g., 1991-01-31):
*Program:
Day (6-10 yrs) $610
Overnight (10-14) $1100
ExplorAsian (14-16) $1100
CIT (11-12th grade) $600
Counselor
RA
Camper Phone (format xxx-xxx-xxxx):
Camper Email (format xxx@xxx.xxx):
Referred by (referral camper's AppID, if available):
If not, leave it blank and email registration with details later.
Last 6 digit SSN if CIT/Counselor/RA is over 18 during camp week(format xx-xxxx):
 
*Camper T-Shirt Size:
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult Extra Large
*Address - Street (100 characters max):
*Address - City/Town:
*Address - State (e.g., MA):
*Address - 5-digit Zip Code (e.g., 01719):
 

Parent/Guardian/Emergency Contact Information
NOTE: Please enter as much contact information as possible in case we need to contact you for application or during the camp week.
***The parent's first and last name must match the legal name on government issued ID***
 
*Main Contact Last Name:
*Main Contact First Name:
Main contact Date of Birth (DOB,format yyyy-mm-dd):
Main contact Last 6 digit SSN(format xx-xxxx):
*Main Contact Relationship:
Father
Mother
Guardian
*Main Contact Home Phone (format xxx-xxx-xxxx):
Main Contact Work Phone (format xxx-xxx-xxxx):
*Main Contact Cell Phone (format xxx-xxx-xxxx):
*Main Contact Email (format xxx@xxx.xxx):
 
Secondary Contact Last Name:
Secondary Contact First Name:
Secondary Contact Date of Birth (DOB,format yyyy-mm-dd):
Secondary Contact Last 6 digit SSN(format xx-xxxx):
Secondary Contact Relationship:
Father
Mother
Guardian
Secondary Contact Home Phone (format xxx-xxx-xxxx):
Secondary Contact Work Phone (format xxx-xxx-xxxx):
Secondary Contact Cell Phone (format xxx-xxx-xxxx):
Secondary Contact Email (format xxx@xxx.xxx):
 
Emergency Contact Info (in case parents cannot be reached during emergency situation):
*Emergency Contact Name:
*Emergency Contact Phone (format xxx-xxx-xxxx):
Emergency Contact Relationship:
 

Parent On Duty (POD) Preference
NOTE: One shift required for each child enrolled in Overnight and ExplorAsian program. If you cannot serve POD, please select Paid Waiver. For all other program we encourage parents to help out.
 

*POD Preference

OVERNIGHT/ExplorAsian Program (required)
Parent #1 as POD
Parent #2 as POD
Paid Waiver ( $300 fee)
 
Day/CIT Program (optional)
Parent #1 wants to help
Parent #2 wants to help
 
I am willing to be a POD lead

Roommate Requests
NOTE: If no roommate name is indicated, a roommate of the same gender and age category will be assigned. Roommate request will only be considered if both campers request each other. Ask your friend to put your name as their roommate request. Group request for Overnight Campers will NOT be accepted.
 
Roommate Name:
 

Medical Information
For camper's immunization requirements, please refer to regulations from Mass Department of Public Health.

*Health Insurance Provider:
*Subscriber's Name:
*Doctor's Name:
*Doctor's Phone Number:
 
I grant NECYSC permission to(Check box to grant consent):
Accompany my child to the nearest hospital in case of an Emergency
Secure medical treatment for my child if I cannot be reached
Administer first aid in case of an injury
Administer Tylenol/Ibuprofen/Benadryl/Tums to my child by the camp nurse if needed
Apply insect repellant (bug spray) if needed
Apply Calamine lotion/Bacitracin/Sunscreen if needed
If consent is not granted for any of the above, please explain:
 
*Does your child have any allergies:
Yes
No
If yes, to what?
Reaction and treatment:
Initial to grant permission to treat allergic reactions:
Does your Physician's Health Form list an Epi-Pen as medication prescribed:
Yes
No
If yes, do you understand that you MUST bring two Epi-Pens so that your child can attend camp?
Yes
No
If yes, you must also fill out the NECYSC Medication Permission Slip for the Epi-Pens and submit along with other application forms.
 
*Does your child have any social/emotional concerns we should be aware of?
Yes
No
If yes, please elaborate:
 
Does your child wear?
Glasses
Contact lenses
Hearing aids
 
*Is your child taking any medication?:
Yes
No
If yes, will the camp need to administer the medication to your child during camp?
Yes
No
If yes, please explain dose/frequency/other note; If no, please explain why medication is not needed at camp:
 
*Are there any activities your child should not take part in?
Yes
No
If yes, please elaborate:
 
*Is there anything else the camp should know about in caring for your child?
Yes
No
If yes, please elaborate:
In case of medical emergency: I understand every effort will be made to contact parents/guardians of campers. IN THE EVENT THAT I CANNOT BE REACHED, I HEREBY GIVE MY PERMISSION FOR THE FOLLOWING: THE PHYSICIAN SELECTED BY THE CAMP DIRECTOR MAY SECURE PROPER TREATMENT FOR, HOSPITALIZE, ORDER AND ADMINISTER MEDICATIONS AND ANESTHESIA, PERFORM X-RAYS, SPECIAL PROCEDURES OR SURGERY IF DEEMED NECESSARY BY HIM/HER FOR MY CHILD.
*PARENT/GUARDIAN SIGNATURE(Type in full name):

All Persons authorized For Child Pickup
NOTE: Please list names for all persons including parents that are authorized to pick up your child(ren). We will only release your child(ren) to the authorized persons listed.
 
*Names of Authorized persons:
 

Supplemental Information for CITs/Counselors/RAs

Supplements for the Counselor/CIT/RA application are required and can be found on the website

Please follow the instruction to complete it and email it by application deadline when applicable.

Application/Payment Information
 
NOTE: The camp fee: $1100 for ExplorAsian, $1100 for Overnight, $610 for Day Camp and $600 for CIT.

*Camp Fee:$

Parent On Duty (POD)waiver Fee:
Voluntary Donation (tax deductible receipt will be mailed after camp):$
TOTAL:$
 

I am also applying for financial aid. I will submit 50% of my payment to hold my application. Please download and submit the financial aid application form for consideration. Use original amount for the Camp Fee field and 50% amount for the TOTAL field.

I do not wish my name to be listed with my donation

 

Additional Information
Check if you want us to contact you to place ads in Camp Book
Check if you don't want to publish name/address/phone in camp week-book
Check if you want to publish name/city/phone in day camp car pool list
Check if you want to be added in next year camp Committee candidate list

*Where did you hear about us:

Important Documents
Please access and read our documents on camp rules form via the hyperlinks below and acknowledge consent by checking the boxes below.

By clicking the Submit button below I certify that I have read and understand NECYSC Camp Information and the information provided on this application form is accurate to the best of my knowledge.
NOTE: After you submit this application, please make sure you see a confirmation page. Write down your confirmation number. In order to complete the registration process, you must print and fill out the required forms on the Download Forms page and mail them along with your check to "NECYSC, P.O.BOX 615, Weston, MA 02493" as soon as possible. Please make sure to write your camper's name and confirmation number on the check. The application priority is based on the latest postmark date of receipt of the check and ALL required information. Contact registration@necysc.org if you have trouble to complete online application.