Police and Youth Together 2019 Police And youth together – apply now CLICK TO VIEW THE 2019 PAYT BROCHURE Step 1 of 3 33% Camper Name* First Last Camper Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent Name* First Last Parent Phone Number*Parent Email* What camp will your child be attending?*Regional PAYT - July 29 through August 2, 2019Please select the session of camp that you are applying for. New sessions may be made available in the coming weeks. Locations: Regional PAYT - July 29 through August 2, 2019 Dayton Police FOP Lodge #44: 4275 Powell Rd. Dayton. Look for more information in the coming weeks regarding additional programs in West and East Dayton Student Date of Birth* Students age during camp:*Please enter a number from 10 to 12.Please enter the age your child will be during camp as a whole number (i.e. "10"). PAYT is intended for children 10 - 12 years old. If your child is 9 or 13, please contact Lake Miller at lmiller@nccjgreaterdayton.org to discuss enrollment. Student Grade*Enter student grade as a whole number, for example "6" for sixth grade. This is the grade the student will be entering in the 2019 - 2020 school year. What school does your student attend?*Student Gender*Choose OneMaleFemaleOtherStudent T-Shirt Size*Pick OneYOUTH SmallYOUTH MediumYOUTH LargeYOUTH Extra LargeADULT SmallADULT MediumADULT LargeADULT Extra LargeADULT 2XLADULT 3XLStudent Race/ Ethnic Background*African American/ BlackCaucasian/ WhiteLatino/ aAsianPacific IslanderNative AmericanMultiracialSelect all that applyDoes the student have any special needs or dietary restrictions?*YesNoPlease explain:*List any special needs or dietary restrictions Camp AgreementPlease agree to the following camper agreement:* I agree to the camper agreement Show Full AgreementCamper Agreement For everyone to have a great experience at camp, please read and sign below: I will join in all the activities during the Police and Youth Together Camp. I will respect everyone, their belongings, and their space. I understand that if I don’t follow the rules, NCCJ will call my parent/guardian. I have read and agree to the above. Media Release Please select if you agree with the media release Show Full AgreementI hereby consent to having quotes of my child’s comments, pictures and/or video footage in which they will appear to be used by NCCJ and Police and Youth Together for publicity purposes. We release NCCJ and sponsoring agencies from any obligation or liability arising from use of said comments, pictures or videos. If you wish to NOT have your child photographed or quoted, please do not select this field. Student Health Information(1) If parent/ guardian is not available, please contact:* First Last (1) Emergency Contact Relationship to Student*(1) Emergency Contact Phone*(2) If parent/ guardian is not available, please contact:* First Last (2) Emergency Contact Relationship to Student*(2) Emergency Contact Phone*Please list the students physician and dentist names as well as a contact phone number:*Does the student take medication?*YesNoWhat Medications?Please list any medications that the student takesPlease list any health conditions or operations/ serious injuries that the student has had.* Enter any medical conditions (i.e. ADD, Asthma, Seizures, Etc.) and serious injuries or operations the student has had (i.e. broken arm)Does the student have all required school immunizations up-to-date?*YesNoHealth Exam* I certify the information is correct Show Full AgreementI certify that the information provided is correct and complete so far as I (the undersigned) know, and the person herein described as the student has permission to engage in all prescribed camp activities, on or off The Dayton Fraternal Order of Police Lodge #44 property, except as noted on this health form. I understand that it is the responsibility of the parent/guardian to inform The National Conference of Community and Justice of Greater Dayton of any changes or additions to this form on the day the child arrives at camp. I also certify that the above-named camper has received a health exam from a licensed medical personnel within the past 24 months of time before the camper will be at camp. I have listed any physical condition requiring restrictions on participation in the camp program and a description of such restrictions. I have also listed any current or ongoing treatments or medications. Consent To Treat I give permission to NCCJ Show Full AgreementI give permission to NCCJ and the Police and Youth Together staff to provide routine health care, administer prescribed medications, and seek emergency medical treatment which may include the administration of over-the-counter medications such as, acetaminophens (Tylenol) and topical ointments. If you do not give permission to NCCJ to administer routine health care, please do NOT select this box. Parent NotificationParents/guardians will be notified of an accident/injury/illness of their child if the accident/injury/illness requires any significant medical attention such as, but not limited to, a stay in the health center of more than three hours, possible sprain/strain/fracture/broken bone/concussion/need for stitches, a temperature of 100 degrees or more, any loss of consciousness, or the need to visit a doctor. NCCJ does not provide accident/health insurance. You can file any medical bill incurred with you insurance company.Parent/ Guardian Consent* I have read and agree with the terms Show Full Agreement I have read the application and give consent for my child to attend the 2019 Police and Youth Together Camp at the Fraternal Order of Police Lodge #44 on 4275 Powell Road in Huber Heights from July 29 - August 2, 2019. I give NCCJ of Greater Dayton, RTA and participating Police Agencies to transport my child to and from PAYT at the F.O.P. Lodge and for scheduled follow-up sessions throughout the year. PLEASE SUBMIT APPLICATIONThank you for submitting your application for Police and Youth Together. An NCCJ Associate will reply within two business days to verify we have received your application. If you have any questions, please contact Lake Miller, PAYT Coordinator at lmiller@nccjgreaterdayton.org or by calling 937-222-6225. This iframe contains the logic required to handle Ajax powered Gravity Forms.
