Enrollment Summer Camp

Summer Camp Registration Form

 

Super hero’s name
Super hero’s Birth day
Age as of Sept. 1, 2016
Grade entering Upcoming School Year
Name of Scholl Attended 2015-2016
Mother’s FULL name
Father’s FULL Name
Home address
Home phone No.
Preferred 1st. person to call #
Mom’s work phone #
Dad’s work phone #
Mom’s cell phone #
Dad’s cell phone #
Mom’s email
Father’s email

Check the Week (s) you want your hero to participate in our Summer Camp, Olympics Theme

 

 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9
JUN 06–10 JUN 13–17 JUN 20–24 JUN 27–1 JUL JUL 11–15 JUL 18–22 JUL 25–29 AUG 01-05 AUG 08-12

If one of the parent can’t be reached in case of emergency, please contact:

 

Name:
Relationship with the Super hero
Telephone No.:
Email (s)
Dr. Name
Phone #
Preferred hospital

Additional Information

 

 

Allergies:
Chronic conditions:
Learning conditions
Other:
Emergency medication he/she requires: Epi-pen – Inhaler – Other
YES / NO
Explain why, please

 

Be aware, if some medication is necessary, it must be provided to Kids Language Academy, along with a completed and executed Medication Authorization, ask for this at front desk.

 

Authorization to pick up child

 

I give my permission to the next person (s) to pick up/take my children home from Kids Language Academy LLC on the following dates:

Full Name:

 Monday Tuesday Wednesday Thursday Friday

Child Name(s):

Parent/ Guardian Signature

Please have the person picking up your child have a form of I.D. ready for staff to check.

Please turn in this form ASAP any time you have an alternate person picking up or taking your child home. Thanks

By signing this document, I affirm that, except as indicated in this application form, my child is in good health and able to participate in all activities. With the understanding that safety standards will be met, I release Kids Language academy from possible claims for injury to person or property, which may arise from participation in activities and hereby covenant and agree to hold harmless Kids Language Academy, its employees, agents or representatives from any claim, liability or expense arising out of, or any way connected to, any alleged incident or injury resulting from such participation. In the event of medical treatment, if neither parent not emergency contact is available, I give Kids Language academy permission to transport my child to a medical emergency room for treatment. I also give permission for my child to participate in any onsite summer camp activities offered. I consent to the use of any photos or videos taken of my child during any camp related activities by Kids Language academy for communication with parents via email, facebook, website or otherwise or for any future promotions or publications online, in print or otherwise. I also hereby acknowledge receipt of the policies and procedures for summer camp and acknowledge that I understand them and agree to abide by same.

I also acknowledge that I am contractually responsible for payment of for each weekly camp session that I indicated my child would attend. I acknowledge that even if my child doesn’t attend camp for one or more days during weekly camp session for which is I registered my child to attend that I remain responsible for full payment of weekly camp session fee for each camp session for which I registered my child.

I.D. checked by:IN.