Please Fill out One Application for Each Child

PLEASE FILL OUT ONE APPLICATION FOR EACH CHILD.

Participant

______

Last nameFirst name Age

______

Date of Birth Male/FemaleGrade (2014-2015)

Parent Information

______

Parent(s) or Guardian Name

______

Home AddressCityStateZip

______

Cell PhoneWork Phone Home Phone Email

Emergency Contacts (IF YOU CANNOT BE REACHED) We will call you first!

Name RelationshipCell Phone Home Phone

Dismissal: Adult Authorized to pick up my Child

______

Name Relationship Cell Phone Home Phone

Child Health Data (please complete all information or indicate if N/A)

Chronic illnesses, allergies, or medical conditions______

Dietary Restrictions______

Current medications (send with instructions)______

Physician Name/Phone______Dentist Name/Phone______

Print and return all forms along with payment to:

Moving Minds Camp Registration

Rhonda Noll * 305 Artillery Park Drive – Suite 101 * Ft. Mitchell, KY 41017

859-760-4959 *

movingmindsprep.com

Child’s Name ______

Camp Choices:

I would like to enroll my child for the following camp(s):

The follow camps will be held Mon-Thurs 12:30-3:00

______July 7-10 Wonderful Writing Gr 6 and up

______July 14-17 Math Mysteries Gr 4-6

______July 21-24 Science is Sensational Gr 3-5

______July 28-31 Smart Art Gr 3-6

______July 28-31 Super Strategies Gr 6 and up

______August 4-7 Back to School #2 Gr 3-6

The following camps will be held once a week from 3:30-5:30

Tuesdays:

______July 8,15,22,29, Aug. 5 Book Club Gr 1-3

Wednesdays:

______July 9,16,23,30, Aug. 6 Math Magic Gr 3-4

Fee: $150 per camp/week -Register at least 2 weeks before camp starts: $140 per camp/week

Call for information about family and multi-camp discounts!

Please submit payment with registration. Checks should be made payable to: Rhonda Noll

Camp location: 305 Artillery Park Dr. Suite 101 – directly across from Ft. Mitchell Park

*Please read each section and initial:

PARK AUTHORIZATION: Occasionally Moving Minds will be utilizing the Fort Mitchell Park for various classes. By initialing I give my child permission to walk to the park with authorized staff.

Initial______

PARENT AUTHORIZATION: I hereby do declare my child to be physically sound, having medical approval to participate in the activities of the Moving Minds program. In consideration of my child’s participation in the activities of Moving Minds Summer Camp, I do hereby agree to hold free from any and all liability the Company and its respective officers, employees and consultants arising out of or connected with my child’s participation in any of the activities of the program. I authorize any representative of the Moving Minds program to seek medical attention for my child when immediate medical care is warranted by the circumstances and I cannot be reached, or if under the circumstances there is no time to attempt to reach me because of the nature of the injury or illness. I further authorize the health care professional selected by the agency to provide the necessary care and treatment for my child.

.Initial ______

PHOTOGRAPHIC AUTHORIZATION: I give permission and consent for Moving Minds to allow photographs to be taken during camp activities. I further give permission and consent that any such photographs may be published and used by Moving Minds to promote the camp experience and its programs.

Initial ______

Parent/Guardian SignatureDate

Printed Name