Round Lake Campus
Youth Registration Form
STUDENT INFORMATION Child Name: ____________________________________
Gender: Male / Female / Prefer not to answer
Nickname:______________________________________
Current grade: ______________________
Age: ____
Program Title: ___________________________________
Date of Birth (mm/dd/yy): _______________
Program Dates: __________________________________
PARENT / GUARDIAN INFORMATION ______________________________________________ Parent / Guardian 1: Name ______________________________________________ Relationship to child ______________________________________________ Address City/State/Zip ___________________________________________ Home phone Work phone ______________________________________________ Cell Preferred email _____________________________________________ Business name Occupation _____________________________________________ Business address Parents are
* married
* separated
______________________________________________ OPTIONAL Parent / Guardian 2: Name ______________________________________________ Relationship to child ______________________________________________ Address (if different) City/State/Zip ______________________________________________ Home phone Work phone ______________________________________________ Cell Preferred email ______________________________________________ Business name Occupation ______________________________________________ Business address
* divorced
* widowed
* single
* foster
TUITION AGREEMENT After receiving your registration form, the tuition agreement is complete with a signature from North Country School. I have read the TUITION PAYMENT POLICY and agree to the payment and penalty terms. I understand all billing will be via email and sent to the address listed below. Please indicate your payment installment frequency: One / Two Please initial (________) and date (____ / ____ / ____). PARENT/GUARDIAN 1 SIGNATURE:
Date:
NORTH COUNTRY SCHOOL SIGNATURE:
Date:
ROUNDLAKECAMPUS.COM I 4382 CASCADE RD. I LAKE PLACID, NY 12946 I (518) 523-9329 E XT. 5440
Round Lake Campus
Youth Registration Form Tuition Payment Policy Tuition Payments Tuition is due 30 days before the program start date. Installments are calculated by dividing tuition (less any deposit received) by installment frequency. One Installment Two (2) installments Three (3) installments
DUE upon admission DUE upon admission and within 30 days of start date DUE upon admission, 60 days before start date, and 30 days before start date
Forms of Payment We accept payment by check or credit card. Checks can be made out to North Country School and sent to 4382 Cascade Rd, Lake Placid NY 12946. To arrange for payment by credit card, please contact Bunny LeClair at bunny@northcountryschool.org or (518) 523-9329, ext. 5455. Non-Sufficient Funds (NSF) and Late Fees You are responsible for any NSF fees incurred by North Country School. Payments must be received by the deadline or within a 3-day grace period. There will be a flat fee of $25 applied to payments that are made after 3 business days from the due date. Cancellation Fees Please notify Peter Bullock at pbullock@roundlakecampus.com to cancel. Allowing switches to a different session is determined case by case, based on circumstances and availability. • Cancellation notice given at least 60 days prior to your session will receive a full refund minus your deposit. • Cancellation notice between 60 and 30 days of your session will receive a refund of 50% minus your deposit. • Cancellation notice given within 30 days of your session will not receive a refund. • Medical or family emergencies will be considered with on an individual basis. • Please contact us with questions or concerns ROUNDLAKECAMPUS.COM I 4382 CASCADE RD. I LAKE PLACID, NY 12946 I (518) 523-9329 E XT. 5440
Round Lake Campus
Youth Registration Form POLICIES & PROGRAM EXPECTATIONS We are committed to promoting the physical and emotional wellbeing of all our program participants. Our program policies help to ensure that all participants in our programs feel safe, respected, and comfortable. Round Lake Campus programs are an extension of North Country School and Camp Treetops, Inc. and will be known as “NCT� herein. Participation Unless health reasons prevent it, students are expected to be present and engaged participants in all program activities. Cell phones & technology Students are allowed to use their cell phones and Wi-Fi during designated free time at the Eileen Rockefeller House. During active programming, including meals, we ask students to show respect to their peers, their instructors, and the natural world by keeping their devices on airplane mode and out-of-sight. Alcohol We have a zero-tolerance policy for drugs and alcohol, which are under no circumstances allowed. Use and possession of illegal substances will result in immediate dismissal from the program. Independence Students will periodically have time during the program when they are unaccompanied by an adult. This includes independent time in the Eileen Rockefeller House when there is an adult in the building, though not directly in the same room as the student. During these periods, it is expected that students act responsibly, follow program expectations, return on time, and interact courteously with community members. Respect for one another We expect our program participants to respect themselves and others. Should a program participant in any way disrespect themselves, other program participants, staff, or educators, that person may be asked to leave the program. Property Students are expected to follow all house rules concerning quiet hours and respect for house property. They are expected to remain on house property except for active programming with a program instructor or staff member. Consequences for student misconduct: Should a program participant misbehave, NCT educators and staff will take the following actions: 1) Review expectations and program policies with student 2) Call parent or guardian for conference 3) If inappropriate behavior continues, the student may be asked to leave the program. No program refund is provided in this situation. ACKNOWLEDGEMENT AND ACCEPTANCE OF POLICIES I, the undersigned parent or guardian, acknowledges having received, reviewed and agreed to the policies set forth above: PARENT/GUARDIAN 1 SIGNATURE: Date: PARENT/GUARDIAN 2 SIGNATURE:
Date:
I, the program participant, acknowledge having received, reviewed and agreed to the policies set forth above: PARTICIPANT SIGNATURE:
Date:
ROUNDLAKECAMPUS.COM I 4382 CASCADE RD. I LAKE PLACID, NY 12946 I (518) 523-9329 E XT. 5440
Round Lake Campus
Youth Registration Form ACKNOWLEDGEMENT OF RISKS, ASSUMPTION OF RISK AND RESPONSIBILITY, AND RELEASE OF LIABILITY WARNING: Round Lake Campus programs are an extension of North Country School and Camp Treetops, Inc. and will be known as “NCT” herein. There are significant elements of risk in the participation of any outdoor sport including hiking, skiing, rock/ice climbing, canoeing, camping, mountain biking, horseback riding, or other outdoor activities. We take reasonable steps to provide (and at other times recommend) appropriate equipment, facilities and skilled instructors so you can enjoy an activity for which you may not be skilled. However, we wish to remind you that any outdoor activity is not without risk. Certain risks cannot be eliminated without destroying the unique character of the activity. The same elements that contribute to the unique character of the activity can be causes of loss or damage to your personal equipment, or accidental injury, or the possibility of extreme injury, or even death. PLEASE REVIEW AND ACKNOWLEDGE THE FOLLOWING: •
ACKNOWLEDGEMENT OF INHERENT RISKS: While the staff of NCT aim to provide a safe and enjoyable experience, I acknowledge that there can be personal injury or even death as a risk inherent with outdoor activities as a participant.
•
ASSUMPTION OF RISK AND PERSONAL RESPONSIBILITY: Knowing the physical risks inherent in outdoor activities, I understand that I must assume responsibility for my/my child’s own safety and the safety of other participants. This responsibility requires that I obey all rules and guidelines provided to me and ask questions if I do not understand instructions given by NCT instructors or staff. Further, I agree to be alert to the condition of all equipment I may use or bring for use and immediately report to an instructor/staff any perceived defect in equipment. I understand that I am required to wear a helmet if instructed as a participant for most outdoor activities, regardless of age.
•
RELEASE OF LIABILITY: In consideration for the services provided by NCT, I hereby waive, release and hold harmless NCT, its board members, faculty, staff, organizers, volunteers or agents and any other persons connected with the institution, from any and all claims for liability, injury, disability, death or loss or damage arising from participation in this activity in the presence of the institution. In addition, I give the institution permission and authority to obtain medical aid or treatment in the case of injury including but not limited to performing any first aid or remedial procedure that is deemed necessary or advisable. I also assume all risk and liability with respect to any claim I may have as a result of my use of any equipment or my participation in activities with any person I bring to assist in such activities. I also give permission for the institution to obtain and use any video, film or photographs of myself as a participant, which may be used for promotional purposes. I have read and understand the foregoing acknowledgement of risk, assumption of risk and responsibility, and release of liability. I understand that by signing this form I may be waiving certain legal rights.
Name of Participant: ________________________________Age: ______________ Signature (if 18 or older): ____________________________Date _____/_____/_____ Emergency Contact: ________________________________Emergency Phone #:____________ If Participant is under 18, a parent or guardian must sign this release: Name of Parent/Guardian (please print):______________________________________ Parent/Guardian Signature: ____________________________ Date: ________________ Email Parent/Guardian: ____________________________________________________ ROUNDLAKECAMPUS.COM I 4382 CASCADE RD. I LAKE PLACID, NY 12946 I (518) 523-9329 E XT. 5440