www.vivaelespanol.com www.stepbysteplanguage.com

. 2017 Registration Form (One form per camper)

Camper’s Last Name______First Name______Age ____ Birthday______

Street Address______City______State______Zip Code______
School______Grade (Next Fall)______Previous camper? Yes____ No____
Parent 1 Last Name______First Name______Email____________
Cellphone Number______Work Number______Home Number______

Parent 2 Last Name______First Name______Email____________
Cellphone Number______Work Number______Home Number______

Tell us about your child’s special needs, allergies, and medications______
Emergency Contact Person______Relationship______Phone ______
Pediatrician______Phone ______Medical Ins. ______Policy # ______
Who else is authorized to pick up your child? Name______Phone ______
Mark with an X the appropriate selection:
Session A ___ 06/12- 06/23 (2 weeks) $ 590____ $___ if registered by 05/08/17___ Lunch $ 70__ (optional) Tot. $______


Session B ___06/26 – 07/07 (2 weeks) $ 590 ____ $___ if registered by 05/08/17__ Lunch $ 70__ (optional) Tot. $______

Session C ___07/10 – 07/21 (2 weeks) $ 590 ____ $___ if registered by 05/08/17__ Lunch $ 70__ (optional) Tot. $______

Session D ___07/24– 08/04 (2 weeks) $ 590 ____ $___ if registered by 05/08/17___ Lunch $ 70__ (optional) Tot. $______

Session E ___08/07 – 08/11 (1 week) $ 330 ____ $___ if registered by 05/08/17___ Lunch $ 35__ (optional) Tot. $______

AFTER CARE AVAILABLE UP TO 5:30 PM ($15 per day or $60 per week) After Care $______

REGISTRATION FEES WAIVED FOR SIBLINGS Registration $25 $______

Camp Hours: 9:00 am to 2:30 pm

TOTAL $______

PAYMENT METHOD (Mark with an X)

1.  Check (payable to Step By Step Languages) ______Check # ______

2.  Cash______

3.  Credit card ___ Visa ___ Master Card ___ Amex___

I hereby authorize Step By Step Languages to charge my account in the amount of $______

Credit Card #______-______-______-______Exp. Date ______CVV______

Cardholder______Signature ______

Credit Card Account Billing Address______zip______

Disclaimer and release: I hereby release, and waive my right to make a claim against, Step By Step Languages and The Riviera Presbyterian Church for any liability or damage arising from claims related to the camp activities, including claims for any injury sustained by my child(ren) while participating in any camp program. I authorize Step By Step Languages to have my children treated in the event of an accident or injury if none of the above contacts can be reached. Cancellations and refunds: Fees are non-transferable and non-refundable. However, if requested in writing prior to the beginning of the session, credit will be given for another session.
I certify that I have read this document and that I understand and agree to all of the foregoing information, terms, and conditions.
Parent’s/Guardian’s Signature:______
Print Name:______Date:______
We love to use photos and video clips in our promotional material. May we use your child’s image, please initial here:____

Mail to: Step By Step Languages, 7550 SW 57 Ave. #106. Miami FL 33143 or email to : email: