DMSC Jr.

2015 – 2016 Registration Packet

·  Please complete entire packet. Print legibly.

·  Students are accepted on a first-come, first-served basis. Please mail this form the Des Moines Social Club, 900 Mulberry Street, Des Moines IA 50310 or scan and email to at your earliest convenience.

·  If you have any questions, call 515-369-3672 or email

·  Please complete all sections not marked optional

STUDENT #1 INFORMATION
Student Name:
Student Age: / Gender:
School: / Grade:
Birth Date:
May the Des Moines Social Club use photos of your child at camp on promotional materials in the future? ___ YES ___NO
Please Select Enrollment Option:
(Note that your initial registration will be an additional $15 to account for registration fee)
___ 5 Days per week at $75 per week
___ 3 Days per week at $60 per week
Please specify which three days: M T W TH F
___ 2 Days per week at $55 per week
Please specify which two days: M T W TH F
___ One Day per week at $35 per week
Please specify which day: M T W TH F
PARENT/GUARDIAN INFORMATION
Parent/Guardian #1
Name:
Cell Phone:
Work Phone:
Home Address:
Email:
Employer/Occupation:
Parent/Guardian #2 (Optional)
Name:
Cell Phone:
Work Phone:
Home Address:
Email:
Employer/Occupation:
Other People Allowed to Pick Up Your Child
Name: / Phone: / Relationship:
Name: / Phone: / Relationship:
Name: / Phone: / Relationship:
Person responsible for payment of account:
Emergency Information
Please inform The Des Moines Social Club immediately of any changes to this information.
Emergency Contact #1
Name:
Cell Phone:
Work Phone:
Home Address:
Relationship to child:
Emergency Contact #2
Name:
Cell Phone:
Work Phone:
Home Address:
Relationship to child:
Emergency Contact #3
Name:
Cell Phone:
Work Phone:
Home Address:
Relationship to child:
Medical Information
Doctor to call at expensed of parent/guardian:
Phone number:
Dentist to be called at expense of parent/guardian:
Phone number:
Hospital to be sent to in case of emergency:
Allergies:
Medications:
Special Needs or Other Concerns:
Any medication to be dispensed during DMSC Jr. must be brought in the prescription container with written directions on how to dispense the medication.
Over-the-counter medications may only be given with a doctor’s written permission.
Any additional information you would like to share:

My signature below verifies that all information above is correct to the best of my knowledge. I understand that any violation of DMSC Jr. policies and procedures may result in my child being removed from the program.

Parent or Guardian’s Signature______Date:______