NORTHVILLE YOUTH NETWORK

CAMP Hillside & Meads Mill Registration

Student Information

Name and age of sibling(s). Click + to add additional entries.
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Does your child have an IEP? *
Does your child have a 504 Plan? *
It is requested that you provide a copy of your child's IEP or 504 Plan so that the teaching staff can better accommodate your child's needs. You can send a copy of the document along with the registration fee. Please note that IEP/504 Plan eligibility in no way limits a child's ability to participate in the CAMP program. In fact, priority is given to those children that face additional obstacles to academic success and who would benefit from the support, resources, and encouragement that the CAMP program provides.
Does your child have any known medical issues we should be aware of? *
Does your child have any allergies we should be aware of? *
Does your child carry an Epipen? *
Does your child carry an inhaler? *

Parent/Guardian & Emergency Contact Information

Select one
Select one
Select one
Select one
Select one *
Child has permission to walk or ride his/her bike home at dismissal time if applicable

Parent/Guardian Waivers & Certification

I understand that checking these boxes constitutes a legal signature confirming that I acknowledge and agree to the below.
I give my informed consent and permission for my child to participate in the Northville Youth Network CAMP Program and its related activities. *
I hereby allow Northville Youth Network representatives including staff and volunteers to secure emergency medical treatment for my child until I can be reached. *
I authorize representatives and staff of the Northville Public Schools to release to the Northville Youth Network Program and volunteers all information requested by it, its agents, servants and professional employees. Northville Youth Network may also release information regarding participation in its programs to representatives and staff of the Northville Public Schools and representatives and staff of the CAMP Hillside and CAMP Meads Mill. *
I release the Northville Youth Network Program of all liability of injury, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any Northville Youth Network mentor, program staff, or other representative, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined. *
I agree to allow Northville Youth Network to use any photographic image of my child taken while participating in the CAMP program. These images may be used in promotions, news stories, or other related marketing materials. *
Parent/Guardian Signature
By signing below, I attest to the truthfulness of all information provided and agree to all the above terms and conditions. *
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NORTHVILLE PUBLIC SCHOOLS
FIELD TRIP PERMISSION SLIP AND SAVE HARMLESS AND RELEASE OF LIABILITY
 
The Parent(s) or Guardian grant permission for their child participating int the CAMP Hillside/Meads Mill program (hereinafter called “the student”) to attend TreeRunner West Bloomfield Adventure Park. The Parent(s) or Guardian understands that the attendance at the activity is not required by the School District and that attendance by the student is strictly on a voluntary basis.

The Parent(s) or Guardian acknowledges that the student is to abide by the rules, regulations and directions of School District employees and/or chaperones during the attendance at this activity.

In consideration of the student participating and attending the activity, the Parent(s) or Guardian on their behalf and on behalf of the student agree:

a. To discharge and release the Northville Public Schools School District, its Board of Education, employees, agents, representatives and the activity chaperones from all claims, demands, damages, suits, actions, cause of action and all liability whatsoever, in law or in equity, which may accrue or arise during, out of or be related to the student attending the activity, including, but not limited to the student attending the activity, including, but not limited to, all liabilities and/or claims resulting from the negligence of the released parties for all injuries to the student, and all liabilities and/or claims for injuries to the student arising out of, or related to, his/her transportation to and from the activity.

b. To indemnify and save harmless the Northville Public Schools School District, its Board of Education, employees, agents, representatives and the activity chaperones from and against all claims, demands, actions, causes of action, suits, damages, including, but not limited to, all damages, court costs and attorney fees as a result of any injury or damages to persons or property resulting from any acts of commission or omissions of the student.

c. To reimburse the School district for any costs associated with transporting the student from the activity to home if, in the sole judgement of the School District, its employees or chaperones, it is determined that the student should be sent home prior to the regular departure date.
 
NPS Policy REV6-10
Adopted: November 1991
Revised: August 2009
Revised: June 2010 (Parent Involvement)
Parent/Guardian Signature *
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NORTHVILLE PUBLIC SCHOOLS
FIELD TRIP PERMISSION FORM TRANSPORTATION BY DISTRICT OWNED/RENTED BUSES

N/A      I am willing and available to chaperone this field trip activity.

SCHOOL BUS: ____X____ RENTED BUS: _________
 
My child/children named in the above registeration form has/have my permission to attend the field trip to TreRunner West Bloomfield Adventure Park on:
Tuesday, August 13 - CAMP Hillside
Wednesday, August 14 - CAMP Meads Mill


SIBLINGS ARE NOT ALLOWED TO ATTEND FIELD TRIPS INVOLVING DISTRICT
OWNED/RENTED BUSES

I understand that my child will be transported by a school bus/rented bus and will be supervised at all times and that the Northville Public Schools cannot be held responsible for any accidents that may occur. I also understand the No Fault Insurance Law as it applies to students who are passengers in school district vehicles.

No Fault Insurance Law
Students Who Are Passengers In School District Vehicles
Personal Injury Protection is provided by the student’s family automobile insurance. The District’s insurance carrier would only assume responsibility for personal injury if there were no insured autos in the student’s family. The District would be liable for serious injury if the driver of the district’s vehicle was at fault for the accident.
 
NPS REV6-10
Adopted: Novemner 1991
Revised: August 2009
Revised: June 2010 (Parent Involvement)
Parent/Guardian Signature *
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Registration Fee

The registration fee to participate is $170.00 A registration is not complete until the registration fee has been received.
 
Please send a check for the registration fee in the amount of $170.00 made payable to:
 
Northville Youth Network
303 W. Main St., Northville, MI 48167
Limited scholarships are available to participants for which the registration fee presents a financial hardship. Checking "Yes" below indicates that you would like to receive a scholarship application form for your child to be considered for a scholarship.
Please provide the name, age and relationship to child of all individuals living in the household. Click + to add additional entries.
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FINANCIAL INFORMATION

Eligibility for need-based scholarships is based on the following table of income and family size (185% Federal Poverty Guideline). If an applicant doesn’t fall within these criteria but can document other special circumstances, he or she may be considered for a scholarship.
 
Total Household Size      Yearly Income
2                                          $30,451
3                                          $38,443
4                                          $46,435
5                                          $54,427
6                                          $62,419
7                                          $70,411
STATEMENT OF NEED
The undersigned, as parent/guardian of the child named above understands that scholarships are need based, and confirms that the child would not be able to attend CAMP Hillside or CAMP Meads Mill without financial assistance from Northville Youth Network.
Parent/Guardian Signature *
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