Youth and Teen Program Application1Personal2Medical3Agreements / Consent / Releases4Education Releases5Child's HealthPRIMARY PARENT/GUARDIANName(Required)Relationship to Child(Required)Address(Required) Street Address Address Line 2 City 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 State ZIP Code Is your mail address different? YesMailing Address Street Address Address Line 2 City 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 State ZIP Code SECONDARY PARENT/GUARDIANName(Required)Relationship to Child(Required)Address(Required) Street Address Address Line 2 City 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 State ZIP Code Is your mail address different? YesMailing Address Street Address Address Line 2 City 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 State ZIP Code STUDENT INFORMATIONChild's Name(Required)Date of Birth(Required) Month Day YearAge(Required)Please enter a number less than or equal to 99.School(Required)Grade(Required)Sex of Child(Required)MaleFemalePrefer not to answerChild's NameDate of Birth Month Day YearAgePlease enter a number less than or equal to 99.SchoolGradeSex of ChildMaleFemalePrefer not to answerADDITIONAL EMERGENCY CONTACTS & AUTHORIZED PICK-UP LISTEmergency Contact & Authorized Pick-Up List(Required)Please list the names of individuals who may be contacted in an emergency if the primary parent/guardian cannot be reached. Anyone NOT listed below WILL NOT be allowed to pick up your child. A picture ID will be required at pick up. Must list at least two contacts.Contact/Pick-UpRelationship to ChildPhone Add RemoveMEDICAL INFORMATIONDoes the child have known allergies, dietary restrictions, or medical conditions?If yes, list: Child’s name, allergy, restrictions, conditions, and treatment.Note: This center is not authorized to administer medications to children.MEDICAL AUTHORIZATIONInsurance CompanyPolicy NumberDoctor’s NameDoctor's Address Street Address Address Line 2 City 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 State ZIP Code Preferred HospitalGHSSt. FrancisPROGRAM AGREEMENTS / CONSENT / RELEASESProgram Agreement(Required)I understand that I am responsible for paying for every week that my child is enrolled in the program. I understand that I must give Pleasant Valley Connection a two week notice before removing my child from the program. I also understand fees and deposits are non-refundable. I also give consent for my child to be transported by Pleasant Valley Connection staff in Pleasant Valley Connection vehicles for pick-up and field trips (if applicable). In the event of an emergency in which I cannot be reached, I authorize medical personnel to provide the necessary first aid and/or hospitalization of my child. I understand that I am responsible for the payment of any medical expenses. I understand that the Summer Day Camp hours are 7:30am-5:30pm and that a $ 1.00 per minute late fee will be assessed for every minute after 5:30pm that my child is not picked up.Consent to Release of Academic Records,(Required)I grant consent to my child’s school, for the release of my child’s academic records, MAP and PASS scores, attendance records and any disciplinary incidents (i.e. referrals, detentions, etc.) to PLEASANT VALLEY CONNECTION staff; and furthermore, I grant permission to employees of PLEASANT VALLEY CONNECTION to facilitate meetings with teachers, guidance counselors, and other school officials as necessary to share and receive information regarding my child’s progress at the school named above and at PLEASANT VALLEY CONNECTION.Waiver and Release(Required)I give permission for him/her to participate in the 2024 Pleasant Valley Connection Summer Day Camp program. I understand that program activities involve outdoor games, travel to and from special activities, and other physical activities which can cause bodily injury. I hereby release and hold harmless PLEASANT VALLEY CONNECTION, its agents, and employees from any liability for any injuries or damages resulting from participation in the 2021 Summer Day Camp Program.Photo Release(Required)I understand that photographs of participants may be taken during programs, and I give permission for Pleasant Valley Connection to use those photographs in publicity materials.PG Movie Release(Required)My Child(ren) has permission to view rated G-PG movies.Off-Site Activity Consent(Required)I give permission for my child(ren) to participate in off-site activities, including swimming, as a participant in The Pleasant Valley Connection, Inc. 2024 Summer Camp.Transportation Consent(Required)I give permission to Pleasant Valley Connection to Transport my child(ren) in Pleasant Valley Connection vehicles to activities as a participant in the 2024 Summer Camp.CONSENT FOR ACCESS/RELEASE OF EDUCATIONAL RECORDSI understand that a student's education records are confidential and may only be disclosed as allowed by the Family Educational Rights and Privacy Act of 1974 or with the written permission of the student's parent, legal guardian, or eligible student (who has reached 18 years of age or attends a postsecondary school).I request that Greenville County Schools provide copies of/or access (verbal and/or written) to education records as specified below:Student InformationStudent's Full NameAs it appears on the education records. First Middle Last Date of Birth Month Day YearRecords to ProvideSelect all that apply Access to the following records (verbal and/or written) Copies of recordsSpecify Records(If you do not identify specific records, GSC will provide access to the entire educational record)Person having access to (verbal and or/written), or copies of RecordsName First Middle Last Position or AgencyAccess PurposeConsent for Release of InformationI authorize the above named person to have access to (verbal and/or written), or copies of the above specified records for the listed purpose. I understand that this authorization can only be revoked by my written requestI am the parent of the named student the legal guardian of the named student an eligible studentGENERAL RECORD AND STATEMENT OF CHILD'S HEALTH FOR ADMISSION TO CHILD CARE FACILTYThis form is to be completed for each child at the time of enrollment in the child care facility, updated as needed when changes occur, and maintained on file at the facility.Name of FaciltyCountyAddressChild's Name(Required) First Middle Initial Last Nickname Date of Birth(Required) Month Day YearEnrollment DateChild's Current Home Address(Required) Street Address Address Line 2 City 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 State ZIP Code Parent/Guardian's Full Name(Required)Home PhoneWork PhoneOther PhoneParent/Guardian's Full NameHome PhoneWork PhoneOther PhoneAuthority to Obtain Emergency Medical TreatmentYou must have two individuals who have the authority to obtain emergency medical treatment for the child.Full Name(Required)Relationship(Required)Address(Required) Street Address Address Line 2 City 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 State ZIP Code Phone(Required)Family Code WordsFull Name(Required)Relationship(Required)Address(Required) Street Address Address Line 2 City 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 State ZIP Code Phone(Required)Family Code WordsIs Child currently enrolled in school? (5K up to 6 years old)(Required) Yes NoMy Child will regualry attend this facility from:If Child is a drop-in, indicate hours of care from:Ex: 2:00 PM to 5:00 PMChild will regularly attend this facility(Required)Check all that apply Sunday Monday Tuesday Wednesday Thursday Friday SaturdayMeals Child will receive daily(Required)Check all that apply Meals are not offered Breakfast Morning Snack Lunch Afternoon Snack Dinner Evening SnackHealth InformationTo be completed by Parent or GuardianFamily Physician or Health Resource Name(Required)Family Physician or Health Resource Address(Required) Street Address Address Line 2 City 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 State ZIP Code Emergency Care Provider Name(Required)Emergency Care Provider Address(Required) Street Address Address Line 2 City 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 State ZIP Code Dental Care Name(Required)Dental Care Address(Required) Street Address Address Line 2 City 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 State ZIP Code Health Insurance Provider(Required)Certificate of Immunization(Required) Yes No OtherMy child has the following health conditions such as allergies, asthma, diabetes, epilepsy, etc., and/or takes the following medications on a regular basis.Child is able to participateI certify that to the best of my knowledge my Child is in good mental and physical health and able to participate in the child care program at Pleasant Valley Connection.
