PAINT BRANCH MONTESSORI SCHOOL
SUMMER DAY CAMP REGISTRATION FORM
1. CAMPER INFORMATION
Camper Name: ______Age: ______DOB: ______
Male ___ Female ___ T Shirt Size: ______
Parent/Guardian’s Full Name: ______E-mail Address: ______
Street Address: ______City/State/Zip: ______
Mother/Guardian Name: ______(H) ______(W) ______(C): ______
Father/Guardian Name: ______(H) ______(W) ______(C): ______
Emergency Contact Name: ______(H) ______(W) ______(C): ______
Emergency Contact Name: ______(H) ______(W) ______(C): ______
Maryland School attended this year: ______
Please Note: A camper who does not attend a Maryland public or private school, Kindergarten through 12th grade must attach an age appropriate immunization record to this form (i.e., home schoolers, out of state schools). Is this camper exempt from immunization for religious or medical reasons? __ Yes __ No. If yes, the Maryland Department of Health and Mental Hygiene Immunization Certificate must be completed and attached to this form.
2. HEALTH INFORMATION
Primary Care/Clinic Name: ______Phone Number: ______
Health Insurance Co.:______Policy #: ______
Date of last tetanus or DPT shot (required by state law) Month/Year: ______
______
______
Camper has Allergies? Yes __ No __. If yes, specify, including medication: ______
______
______
Camper currently takes medication (excluding allergy medication)? Yes __ No ___. If yes, name the medicine, dosage, times given, and doctor’s name. ______
______
Camper requires special health care: If yes, please explain (i.e. inhaler, EpiPen, etc.).______
______
______
3. CAMPER RELEASE AUTHORIZATION
The Paint Branch Montessori School (PBMS) Summer Camp is authorized to release my Child, ______
Camper’s Name
to the following individuals who may pick up my child from the Summer Camp. I understand that each authorized person must be at least sixteen (16) years old, and my child will not be permitted to leave the camp with anyone not listed below. All authorized individuals will be required to show identification and sign the child out each day. My child may be released to the following:
Name Phone Number Relationship
1. ______
2. ______
3. ______
4. ______
4. LATE PICK UP POLICY
A late fee will be assessed for campers who are not picked up by the program’s scheduled closing time (6:00 pm). The PBMS Summer Camp’s Policy is $5 per minute increments with a minimum of $15.00.
We understand that emergencies do arise and request that parents call the school office if they are delayed. However, late charges may still be assessed. Payment is due by 4:30 pm the next business day.
Thank you for your cooperation in ensuring your camper is picked up from the program on time.
5. ACTIVITY/PROGRAM FIELD TRIP LIABILITY RELEASE/AUTHORIZATION
I hereby give permission for the applicant to camper in all program activities and agree to release Kirat Enterprises and its officers, employees, and agents, from all liability arising from any harm or injury incurred by the camper of my child in the summer camp program.
I hereby represent and warrant that if the camper is a minor, I am his/her parent or guardian and am authorized to provide the released authorizations and permissions as stated below.
If you do not want Paint Branch Montessori School to use pictures of your child in it’s marketing efforts, please submit your wishes in writing at registration. No personal information other than the camper’s first name will be released under any circumstances.
This form authorizes Paint Branch Montessori School to obtain medical/hospital treatment for the above camper in the event of an emergency.
X______
SIGNATURE OF PARENT/GUARDIAN Date
______
Print name of parent/guardian Date
X______
SIGNATURE OF PARENT/GUARDIAN Date
______
Print name of parent/guardian Date
Name of Child / Half Day (H)Full Day (F) / Date of Weeks Needed / No. of Weeks / Total Payment
______ / ______
______ / ______
______
______
______
______ / _____ / 1-3 weeks = $250 x ____ = _____
1-3 weeks = $150 x ____ = _____
4 or more weeks = $225 x ____ = ____
4 or more weeks = $125 x ____ = ____
Registration Fee = $50.00
(Inc. Program T-Shirt)
Total Paid = ______
Check No. ______
Arrival Time: ______Departure Time: ______Nap: Yes __ No __
Please note: registrations will not be processed until all paperwork is COMPLETE and the appropriate payments have been submitted.
MEDICATIONS: If your child requires ANY medication including over the counter medications during the camp day, a Medication Form must be completed and signed by your Physician.
MEDICAL POLICY: If a child becomes ill at camp with vomiting, fever, headache, or shows any symptoms that we feel need attention, we expect the child to be picked up immediately.
MEDICAL FORMS: All required health forms must be on file before the first day of attendance in the Summer Camp. Enrollment will be delayed (no refunds given) for any child whose health forms are not on file before they begin attendance. We reserve the right to dismiss, without a refund, any camper or student for inappropriate or unsafe conduct. We reserve the right to cancel any course, class, program or service for insufficient interest.
I have read and understand all camp policies and fee schedules. ______
Signature of person completing this form
4/25/08 jmc