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City of Clayton Presents:

Summer Camp 2018 June 4 - August 3

Fi n d y o u r

Now Registering!


CAMPS-AT-A-GLANCE Clayton Parks and Recreation offers a variety of camps throughout the summer that cover a wide range of activities, interests, and ages. The grid below shows which camps are offered in the corresponding weeks including the camp's name, ages, time, drop-off / pick-up location, registration code and prices for Members / Residents and Non-Residents. Camp registration is available online at www.claytonmo.gov/camps and at The Center of Clayton.

ACCESSIBILITY TO ALL CITIZENS The City of Clayton welcomes individuals of all abilities to enjoy our programs, parks and facilities, and provides inclusion services to the community through the Mid-County Inclusion Partnership. If you or someone you know requires accommodations or assistance to participate in camps, please notify us at registration and contact Malory Smysor, Inclusion Coordinator, at msmysor@claytonmo.gov or 314-290-8507 two weeks prior to the start of the camp.

WEEKS 1-6: JUNE 4 - JULY 13 The following programs will be held by Clayton Parks and Recreation during the School District of Clayton's SummerQuest program. Please note: No Lunch Bunch June 4- July 13.

Camp Name June 4 - 8 Coed Basketball Jr. Tennis June 11 - 15 SCUBA Jr. Tennis June 18 - 22 Jr. Lifeguard Jr. Tennis June 25 - 29 Water Polo Jr. Tennis July 9 - 13 Jr. Tennis

Ages

Time

Location

Registration

grade 3-8 ages 7-14

9:30a-3:30p 9:00a-12:00p

Stuber Gym (CHS) Code: 4700 Shaw Park Courts Code: 4687

$180 / $190 $185 / $210

ages 8-14 ages 7-14

9:00a-12:00p 9:00a-12:00p

Shaw Park Pool Code: 4683 Shaw Park Courts Code: 4688

$199 / $229 $185 / $210

ages 11-14 9:00a-12:00p ages 7-14 9:00a-12:00p

Shaw Park Pool Code: 4681 Shaw Park Courts Code: 4689

$110 / $140 $185 / $210

ages 6-14 ages 7-14

9:00a-12:00p 9:00a-12:00p

Shaw Park Pool Code: 4685 Shaw Park Courts Code: 4690

$125 / $145 $185 / $210

ages 7-14

9:00a-12:00p

Shaw Park Courts Code: 4692

$185 / $210

Mem & Res / Non-Res

SUMMERQUEST SUMMERQUEST se rinouseslriy!ou sl y! We taWkee tafuken fu SUMMERQUEST has the BEST programs, the BEST SUMMERQUEST the 15 BEST Sessionthe I - BEST Junecamp 4 tohas June facilities, counselors andprograms, the BEST the BEST facilities, camp counselors and the BEST Session II - June 18BEST toHigh June 29 campers! Located at the Clayton School, The Center campers! Located at Clayton High School, Session July Park, 2 to SUMMERQUEST July 13 of Clayton III and- Shaw offers theThe Center of Clayton and Shaw Park, SUMMERQUEST offers the BEST K-8 summer camp experience in St.ofLouis! Produced by the School District Clayton and BEST K-8 summer camp experience in St. Louis! located at ClaytonSession High School, Center I - June 4The to June 15 of Clayton and Shaw Session I June 429to June 15 Session II - June 18offers to June Park, SUMMERQUEST the BEST K-8 summer camp Session II June 18 to June 29 Session III July 2 to July 13 experience in St. Louis! Session III - July 2 to July 13

CALL WWW.SUMMERQUEST.ORG 854-6023 TO REGISTER OR Visit CALL 854-6023 TO REGISTER OR VISIT WWW.SUMMERQUEST.ORG or call VISIT (314) WWW.SUMMERQUEST.ORG 854-6023 for details. 1

314-290-8500

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Summer Camp 2018

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www.claytonmo.gov/camps


CAMPS-AT-A-GLANCE Contact Form Information is used for emergency purposes only. can be accepted. 2016 Emergency year before registration form submitted each

Each camp participant

must have this

_____________

_____________

Child’s Name: _____________

Mother’s Name:

Email: _____________

_

_____________

_____________

_____________

_______

_____________

_____________

Email: _____________

EMERGENCY CONTACTS

(The parent/guardian

listed above is the

) __ Phone ( _____

authorized to pick

Additional persons

- ________ - _____________

) __ Phone ( _____

- ________ - _____________

up child from camp: ______________ ________ Relationship:

______________

1. Name: ______________

contacts)

- ________ - _____________

) __ Phone ( _____

______________ ________ Relationship: ______________

2. Name: ______________

- _________

_____ ) - _______

Please list two additional

primary contact.

______________ ________ Relationship:

______________

1. Name: ______________

○Male ○Female

____

) - ________ - _____________ Cell Phone: ( _____ ) - ________ - _____________ Work Phone: ( _____ ) - ________ - _____________ Cell Phone: ( _____ - _____________ _____ ) - ________ Work Phone: (

_______

_____________

_____________

Home Phone: (

Zip __________ _

_____________

_____________

_____________

Father’s Name:

___ / ____/ Age: _____ D.O.B.

____

_____________

_____________

Address: _____________

) __ Phone ( _____

______________ ________ Relationship:

- ________ - _____________

______________

2. Name: ______________

HEALTH INFORMATION or food restrictions: Please list any

allergies

______

______________

______________

______

______________

______________

______________

______________

______________

______________

______________

______________

______________

______________

______________

______________

______________

______________

Diagnosis: Insect Sting Allergy/Sensitivity any Medical / Educational Convulsions Diabetes ________ Ear Infection(s)/tube ______________ Other ______________ EADD/ADHD Asthma let us know at to participate, please of Inclusive No Yes needs assistance coordinator camp? If you or your child to participate in contact Mary Furfaro, need assistanceall abilities to participate in our programs.For more information please Does your child people of start of the camp. We invite and welcome or at least 2 weeks prior to the 1-800-735-2966 the time of registration ______ 314-505-8607; (TDD) ______________ Services at (voice) ______________ child is taking: ______________ medications your ______________ ______ prescriptions and/or ______________ ______________ Please list any ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ your child: ______ precautions for ______________ recommended ______________ remarks and/or ______________ Please list any ______________ ______ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________

Please indicate

if your child has

□ □

□ □

Camp Name

Lunch Bunch is free for campers enrolled in both an AM and PM camp. $25 fee required for those only registered in one camp. Registration is required.

Ages

Time

Location

Jr. SCUBA Zarky Soccer Jr. Tennis

ages 8-14 ages 5-13 ages 7-14

9:00a-12:00p 9:00a-12:00p 9:00a-12:00p

Shaw Park Pool Code: 4684 Shaw Park Code: 4698 Shaw Park Courts Code: 4693

$199 / $229 $125 / $145 $185 / $210

Lunch Bunch

all ages

12:00p-1:00p

Center of Clayton

Code: 3988

**See above

PM

□ □

LUNCH BUNCH - Please register all campers who will stay with us between AM and PM camps from 12-1 pm. Campers should bring a sack lunch (Sorry, no refrigeration available) or purchase a meal from Subway. Lunch is not provided.

Aquatic Climbing Chess Wizards Fencing Zarky Sports

ages 5-12 ages 8-15 ages 6-12 ages 7-15 ages 5-13

1:00p-4:00p 1:00p-4:00p 1:00p-4:00p 1:00p-4:00p 1:00p-4:00p

Center of Clayton Center of Clayton Center of Clayton Center of Clayton Center of Clayton

Code: 4678 Code: 4702 Code: 4669 Code: 4037 Code: 4696

$125 / $145 $125 / $145 $190 / $210 $190 / $210 $125 / $145

Full

□ Seizure Disorder □ Penicillin Allergy

2018 Emergency Contact Forms must be completed, signed by a guardian and turned in to The Center of Clayton before registration. Find the form online at www.claytonmo.gov/camps.

Registration

Coed Basketball

grade 3-8

9:00a-3:00p

Center of Clayton

Code: 4701

$180 / $190

Water Polo Karate Zarky Soccer Jr. Tennis

ages 6-14 ages 6-12 ages 5-13 ages 7-14

9:00a-12:00p 9:00a-12:00p 9:00a-12:00p 9:00a-12:00p

Shaw Park Pool Center of Clayton Shaw Park Shaw Park Courts

Code: 4686 Code: 4046 Code: 4699 Code: 4694

$125 / $145 $150 / $175 $125 / $145 $185 / $210

Lunch Bunch

all ages

12:00p-1:00p

Center of Clayton

Code: 4005

**See above

Jr. Lifeguard Crayola Design Climbing Fencing Zarky Sports

ages 11-14 ages 5-11 ages 8-15 ages 7-15 ages 5-13

1:00p-4:00p 1:00p-4:00p 1:00p-4:00p 1:00p-4:00p 1:00p-4:00p

Shaw Park Pool Center of Clayton Center of Clayton Center of Clayton Center of Clayton

Code: 4682 Code: 4671 Code: 4703 Code: 4544 Code: 4697

$125 / $145 $175 / $195 $125 / $145 $190 / $210 $125 / $145

Mem & Res / Non-Res

AM

WEEK 7: JULY 16-20

PM

AM

WEEK 8: JULY 23-27

PM

AM

WEEK 9: JULY 30 - AUGUST 3 Water Sports Karate Jr. Tennis Zarky Soccer

ages 6-12 ages 6-12 ages 7-14 ages 5-13

9:00a-12:00p 9:00a-12:00p 9:00a-12:00p 9:00a-12:00p

Shaw Park Pool Center of Clayton Shaw Park Courts Shaw Park

Code: 4680 Code: 4809 Code: 4695 Code: 4894

$125 / $145 $150 / $175 $185 / $210 $125 / $145

Lunch Bunch

all ages

12:00p-1:00p

Center of Clayton

Code: 4004

**See above

Aquatic Earth & Space Climbing Zarky Sports

ages 5-12 ages 5-11 ages 8-15 ages 5-13

1:00p-4:00p 1:00p-4:00p 1:00p-4:00p 1:00p-4:00p

Center of Clayton Center of Clayton Center of Clayton Center of Clayton

Code: 4679 Code: 4670 Code: 4704 Code: 4895

$125 / $145 $175 / $195 $125 / $145 $125 / $145

314-290-8500

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Summer Camp 2018

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www.claytonmo.gov/camps

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AQUATIC camps JUNIOR SCUBA CAMP

AQUATIC CAMP CONTACT

Karen Herbig | 314-290-8572 | kherbig@claytonmo.gov

AQUATIC CAMP

ages 5-12

Participants may improve technique, endurance, and safety awareness while discovering other aquatic activities. Each day includes a swim lesson, game, safety activity, and supervised playtime. Participants will be evaluated on the first day and assigned to small groups based on age and swimming ability. (Min/Max 12/42) Location: Center of Clayton Day Time Code Jul 16-Jul 20 Monday-Friday 1:00p-4:00p 4678 Jul 30-Aug 3 Monday-Friday 1:00p-4:00p 4679 Member / Resident $125 Non-Resident $145

CAMP WATERSPORTS

ages 6-12

Experienced aquatic campers will enjoy this camp that introduces participants to a variety of cool water sports. Each camp day features a different skill set and corresponding water sport, including diving, water polo, snorkeling, surfing, and kayaking/canoeing. (Min/Max 8/26) Prerequisite: Completion of Level 3 or equivalent swim course or demonstration of Level 3 critical skills on the first day of camp.

ages 8-14

This camp uses the PADI Seal Team course curriculum and encourages participants to try SCUBA in a pool under the close supervision of certified professional dive instructors. The structured, non-competitive, and activity-filled environment lets participants develop swimming skills, explore the underwater world, and learn about the use and care of real SCUBA gear as they complete five Aqua Missions. All equipment is included, as well as a DVD of photos taken during camp. Each participant will receive his/her own PADI Seal Team crew pack, which includes Aqua Mission activity book and logbook. Upon completion of camp, each participant will receive a PADI Seal Team member card and wall certificate. Presented by Y-kiki Divers. (Min/Max 6/16) Prerequisites: Minimum age 8 years; completion of Level 2 or equivalent swim course; completed and signed (by parent or guardian) PADI Seal Team statement and medical history form (and, if required, medical approval from a licensed physician) prior to water activities. PLEASE NOTE: Immediately after registration, contact Y-kiki Divers at 314-469-8722 for medical forms. Location: Shaw Park Aquatic Center Day Time Code Jun 11-Jun 15 Monday-Friday 9:00a-12:00p 4683 Jul 16-Jul 20 Monday-Friday 9:00a-12:00p 4684 Member / Resident $199 Non-Resident $229

Location: Shaw Park Aquatic Center Day Time Code Jul 30-Aug 3 Monday-Friday 9:00a-12:00p 4680 Member / Resident $125 Non-Resident $145

JUNIOR LIFEGUARD CAMP

ages 11-14

Junior Lifeguard Camp is a great first step towards a job as a lifeguard. Junior Lifeguard Camp teaches the fundamentals of lifeguarding and will focus on safety awareness and skill development that will enhance the future of each camper while having fun! Campers will be paired up with City of Clayton lifeguards and join in on actual rotations. Junior Lifeguard Camp focuses on 5 key areas: Prevention of aquatic accidents, Fitness and swimming skills, Response in an emergency, Leadership skills, and Professionalism. Presented by Midwest Pool Management. (Min/ Max 6/12) Prerequisites: Must be 11 years old prior to first day of camp. Must be able to swim 25 yards of freestyle and tread water for one minute. Location: Shaw Park Aquatic Center Day Time Code Jun 18-Jun 22 Monday-Friday 9:00a-12:00p 4681 Jul 23-Jul 27 Monday-Friday 1:00p-4:00p 4682 Member / Resident $125 Non-Resident $145

3

314-290-8500

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WATER POLO BEGINNER CAMP

ages 6-14

The City of Clayton offers water polo camps for youth players at all levels of experience. Fundamental skills practiced in each level include treading water, swimming, catching and throwing. Participants will be divided into small groups based on age and playing experience. Presented by Strike Zone Water Polo. (Min/Max 6/24) Location: Shaw Park Aquatic Center Day Time Code Jun 25-Jun 29 Monday-Friday 9:00a-12:00p 4685 Jul 23-Jul 27 Monday-Friday 9:00a-12:00p 4686 Member / Resident $125 Non-Resident $145

Summer Camp 2018

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www.claytonmo.gov/camps


ENRICHMENT camps ENRICHMENT CAMP CONTACT

Ann Jacobs | 314-290-8505 | ajacobs@claytonmo.gov

CHESS WIZARDS SUMMER CAMP

ages 6-12

Chess Wizards is a premier chess education company providing fun, informative and challenging chess lessons to students. Chess Wizards teaches children many important life concepts, such as learning the ability to win graciously and accept defeat with dignity and good sportsmanship. Students will be divided into groups according to their chess experience. At the end of session, each student will have a chance to participate in a mini-chess tournament. (Min/Max 10/24) Location: Center of Clayton, Meeting Room B Day Time Code Jul 16-Jul 20 Monday-Friday 1:00p-4:00p 4669 Member / Resident $190 Non-Resident $210

IMAGINE ARTS ACADEMY: CRAYOLA© - WORLD OF DESIGN CAMP ages 5-11

Take a journey to the farthest reaches of the imagination while learning about rainforest, Hollywood, Mars, and a futuristic city! Use the Design thinking process to solve real-world problems in these different environments. Experiment with Crayola products and a wide variety of art techniques like sculpting, collage, and mixed media. Discover careers like graphic design, fashion design and architectural and urban design. (Min/Max 10/24) Location: Center of Clayton, Meeting Room B Day Time Code Jul 23-Jul 27 Monday-Friday 1:00p-4:00p 4671 Member / Resident $175 Non-Resident $190

MAD SCIENCE: EARTH, SPACE AND BEYOND CAMP ages 5-11

Children will discover how to send secret messages using special codes, explore their environment , and find out how science can help us to protect our planet. Your Junior Mad Scientist will learn how Newton’s laws are at work in their favorite sports, and join the Ranks of space scientist examining the mysteries of the solar system! (Min/Max 10/24) Location: Center of Clayton, Meeting Room B Day Time Code Jul 30-Aug 3 Monday-Friday 1:00p-4:00p 4670 Member / Resident $175 Non-Resident $190 Contact Form Information is used for emergency purposes only. can be accepted. 2016 Emergency year before registration form submitted each

○ ○Female

have this participant must

Male

Each camp ___ / ____/ ____ Age: _____ D.O.B. _____________ - _________ _____ ) - _______ Home Phone: ( Child’s Name: __________________________ Zip __________ _________________ ) - ________ - _____________ Address: __________________________ Cell Phone: ( _____ ______________ ) - ________ - _____________ __________________________ Work Phone: ( _____ Mother’s Name: ____________________ ) - ________ - _____________ Email: __________________________ Cell Phone: ( _____ ______________ - _____________ _____ ) - ________ __________________________ Work Phone: ( Father’s Name: ____________________ Email: __________________________ contacts) Please list two additional primary contact. listed above is the (The parent/guardian - ________ - _____________ Phone ( _____ ) ________________ ________ Relationship: - ________ - _____________ Phone ( _____ ) ________________ ________ Relationship: 2. Name: ____________________________ up child from camp: - ________ - _____________ authorized to pick Phone ( _____ ) Additional persons ________________ ________ Relationship: - ________ - _____________ Phone ( _____ ) 1. Name: ____________________________ ________________ ________ Relationship: 2. Name: ____________________________

EMERGENCY CONTACTS

1. Name: ____________________________

______

HEALTH INFORMATION or food restrictions:

____________________________ allergies ____________________________ ______ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ Diagnosis: Insect Sting Allergy/Sensitivity any Medical / Educational Convulsions if your child has Diabetes Please indicate ________ Ear Infection(s)/tube Other ____________________________ Seizure Disorder EADD/ADHD Asthma Penicillin Allergy let us know at to participate, please of Inclusive No Yes needs assistance coordinator camp? If you or your child to participate in contact Mary Furfaro, need assistanceall abilities to participate in our programs.For more information please Does your child people of start of the camp. We invite and welcome or at least 2 weeks prior to the 1-800-735-2966 the time of registration ______ 314-505-8607; (TDD) Services at (voice) ____________________________ child is taking: medications your ____________________________ ______ prescriptions and/or Please list any ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ your child: ______ precautions for recommended ____________________________ remarks and/or Please list any ____________________________ ______ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

Please list any

____________________________

□ □

□ □

□ □

□ □

2018 Emergency Contact Forms must be completed, signed by a guardian and turned in to The Center of Clayton before registration. Find the form online at www.claytonmo.gov/camps. 314-290-8500

.

Summer Camp 2018

CLIMBING WALL CAMP CONTACT

Patrick Magee | 314-290-8510 | pmagee@claytonmo.gov

CLIMBING WALL CAMP

ages 8-15

Join us for some fun on the Wall! This is a great camp for the beginning or advanced climber. This camp will emphasize safety, ways to improve your skills and ability and most of all having fun. All equipment is included. (Min/Max 2/10)

Location: Center of Clayton, Climbing Wall Day Time Code Jul 16-Jul 20 Monday-Friday 1:00p-4:00p 4702 Jul 23-Jul 27 Monday-Friday 1:00p-4:00p 4703 Jul 30-Aug 3 Monday-Friday 1:00p-4:00p 4704 Member / Resident $125 Non-Resident $145

FENCING OR KARATE CAMP CONTACT Lori Rice | 314-290-8511 | lrice@claytonmo.gov

FENCING CAMP

ages 7-15

The Fencers' Academy is back for another exciting camp season! This camp is geared towards athletes with little or no experience in fencing, while still challenging the experienced participant. Fencing is a sport that develops athleticism, critical thinking, sportsmanship and competitiveness, while providing kids with a dynamic and creative outlet for their energies. Its intensity and fast pace will keep them coming back for more. Coach Hossam, former coach of the Egyptian National team, has trained many internationally ranked fencers. He is joined by Coach Nehal Hassan and Coach Phillip Ferko, who are the highest ranked saber and epee fencers in St. Louis. A tournament will be held at the end of camp. Medals, t-shirt, and certificates are all included in the cost of camp. (Min/Max 6/24) Location: Center of Clayton, Gym 1 Day Time Code Jul 16-Jul 20 Monday-Friday 1:00p-4:00p 4037 Jul 23-Jul 27 Monday-Friday 1:00p-4:00p 4544 Member / Resident $190 Non-Resident $210

YOUTH KARATE SUMMER CAMP

ages 6-12

Sensei David Cloud, our resident 7th Degree Black Belt, returns for another year of summer camp! Kids will build self-confidence, balance, pride, strength, and security. This camp teaches discipline. Homework will be assigned. Uniforms are required and will be available at the first class for an additional charge from the instructor. A karate based movie will be shown in pieces throughout the week during parts of this camp. (Min/Max 9/20) Location: Center of Clayton, Gym 3 Day Time Code Jul 23-Jul 27 Monday-Friday 9:00a-12:00p 4046 Jul 30-Aug 03 Monday-Friday 9:00a-12:00p 4809 Member / Resident $150 Non-Resident $175 . www.claytonmo.gov/camps 4


SPORTS camps PAUL ZARKY'S GET HIGH ON SPORTS CAMP

SPORTS CAMP CONTACT

Patrick Magee | 314-290-8510 | pmagee@claytonmo.gov

Z

ages 5-13

Paul Zarky has established several after school programs in St. Louis. Our campers will help craft a daily schedule with games that may include softball, kickball, soccer, capture the flag and many other healthy exercise options, as well as Paul's special stories and jokes. Make it a full day by signing your kids up for the morning soccer camp too! (Min/Max 10/40) Location: Center of Clayton, Gym 4 Day Time Code Jul 16-Jul 20 Monday-Friday 1:00p-4:00p 4696 Jul 23-Jul 27 Monday-Friday 1:00p-4:00p 4697 Jul 30-Aug 03 Monday-Friday 1:00p-4:00p 4894 Member / Resident $125 Non-Resident $145

GREYHOUND COED BASKETBALL CAMP grade 3-8

The Clayton High School Basketball Coaching staff will teach each camper the fundamental basketball skills that are necessary to compete at the high school level. Individual shooting, passing, ball handling, rebounding, team offense and defense will be emphasized. This is a full day camp. (Min/Max 10/100) Location: Center of Clayton, Gym 3 Day Time Code Jun 4-Jun 8 Monday-Friday 9:30a-3:30p 4700 Jul 16-Jul 20 Monday-Friday 9:00a-3:00p 4701 Member / Resident $180 Non-Resident $190

JUNIOR TENNIS CAMP

ages 7-14

Join our tennis professionals from Frontenac Racquet Club for a unique camp experience. Campers will become better tennis players by participating in a series of age appropriate, fun and exciting games and activities. These innovative games and activities are designed to entertain and nurture development of skills needed to play the game of tennis. (Min/Max 8/20) Location: Shaw Park Tennis Center Day Time Code May 29-Jun 01 Monday-Friday 9:00a-12:00p 4705 Jun 04-Jun 08 Monday-Friday 9:00a-12:00p 4687 Jun 11-Jun 15 Monday-Friday 9:00a-12:00p 4688 Jun 18-Jun 22 Monday-Friday 9:00a-12:00p 4689 Jun 25-Jun 29 Monday-Friday 9:00a-12:00p 4690 Jul 02-Jul 06 Monday-Friday 9:00a-12:00p 4691 Jul 09-Jul 13 Monday-Friday 9:00a-12:00p 4692 Jul 16-Jul 20 Monday-Friday 9:00a-12:00p 4693 Jul 23-Jul 27 Monday-Friday 9:00a-12:00p 4694 Jul 30-Aug 03 Monday-Friday 9:00a-12:00p 4695 Member / Resident $185 Non-Resident $210

5

314-290-8500

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PAUL ZARKY'S COED SOCCER CAMP

Z

ages 5-13

Paul Zarky is the Executive Director for the Athletic Club Porta Via. Paul is a former professional soccer player and collegiate All-American. Your child will work on dribbling, passing, shooting, defensive posturing and attacking skills. Make it a full day by signing your child up for the afternoon sports camp too! (Min/Max 10/40) Location: Shaw Park, Field #6 Day Time Code Jul 16-Jul 20 Monday-Friday 9:00a-12:00p 4698 Jul 23-Jul 27 Monday-Friday 9:00a-12:00p 4699 Jul 30-Aug 03 Monday-Friday 9:00a-12:00p 4895 Member / Resident $125 Non-Resident $145

2016 Emergency

Contact Form year before registration

can be accepted.

Information is used

for emergency purposes

2018 Emergency Contact Forms must be completed, signed by a guardian and turned in to The Center of Clayton before registration. Find the form online at www.claytonmo.gov/camps.

only.

○ ○

submitted each Female Male must have this form Each camp participant ___ / ____/ ____ Age: _____ D.O.B. _____________ - _________ _____ ) - _______ Home Phone: ( Child’s Name: __________________________ Zip __________ _________________ ) - ________ - _____________ Address: __________________________ Cell Phone: ( _____ ______________ ) - ________ - _____________ __________________________ Work Phone: ( _____ Mother’s Name: ____________________ ) - ________ - _____________ Email: __________________________ Cell Phone: ( _____ ______________ - _____________ _____ ) - ________ __________________________ Work Phone: ( Father’s Name: ____________________ Email: __________________________ contacts) Please list two additional primary contact. listed above is the (The parent/guardian - ________ - _____________ Phone ( _____ ) ________________ ________ Relationship: - ________ - _____________ Phone ( _____ ) ________________ ________ Relationship: 2. Name: ____________________________ up child from camp: - ________ - _____________ authorized to pick Phone ( _____ ) Additional persons ________________ ________ Relationship: - ________ - _____________ Phone ( _____ ) 1. Name: ____________________________ ________________ ________ Relationship: 2. Name: ____________________________

EMERGENCY CONTACTS

1. Name: ____________________________

______

HEALTH INFORMATION or food restrictions:

____________________________ allergies ____________________________ ______ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ Diagnosis: Insect Sting Allergy/Sensitivity any Medical / Educational Convulsions if your child has Diabetes Please indicate ________ Ear Infection(s)/tube Other ____________________________ Seizure Disorder EADD/ADHD

Please list any

____________________________

□ □

□ □

□ □

□ □

Asthma Penicillin Allergy let us know at to participate, please of Inclusive No Yes needs assistance coordinator camp? If you or your child to participate in contact Mary Furfaro, need assistanceall abilities to participate in our programs.For more information please Does your child people of start of the camp. We invite and welcome or at least 2 weeks prior to the 1-800-735-2966 the time of registration ______ 314-505-8607; (TDD) Services at (voice) ____________________________ child is taking: medications your ____________________________ ______ prescriptions and/or Please list any ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ your child: ______ precautions for recommended ____________________________ remarks and/or Please list any ____________________________ ______ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

Summer Camp 2018

.

www.claytonmo.gov/camps

Clayton Summer Camp 2018  
Clayton Summer Camp 2018  
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