2024 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 2024 Fall semester):

*Birthday (format yyyy-mm-dd; e.g., 1991-01-31):

*Program:

Day (6-10 yrs) $900

Overnight (10-14) $1800

ExplorAsian (14-16) $1800

CIT (11-12th grade) $1100

Counselor

Camper Phone (format xxx-xxx-xxxx):

Camper Email (format xxx@xxx.xxx):

Sibling 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

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

If yes, do you understand that you MUST bring two Epi-Pens so that your child can attend camp?

Yes

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

If yes, please elaborate:

Does your child wear?

Glasses

Contact lenses

Hearing aids

*Is your child taking any medication?:

Yes

If yes, will the camp need to administer the medication to your child during camp?

Yes

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

If yes, please elaborate:

*Is there anything else the camp should know about in caring for your child?

Yes

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: $1800 for ExplorAsian, $1800 for Overnight, $900 for Day Camp and $1100 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.

*Click here to accept the Camp Rule Agreement

*Click here to accept the Liability and Photo Agreement

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.