Office Use Only: Amount Paid $ ___________ Check Number: __________
Around the World In 30 Days Summer Enrichment Camp
2011 Registration Form June13th 2011 and ending August 5th 2011
Time: 8:00 am until 6:00pm Days: Monday – Friday Sites: 510 S Torrence St. Charlotte, NC 28204 Registration fee: $25.00 cash, money order or check made out to Around The World In 30 Days Summer Camp. Summer Enrichment Camp (non-refundable fee) Weekly: $85.00 Enrollment form is due no later than Friday, May 27nd
Dear Parents, Around the World In 30 Days Summer Enrichment Camp is an excellent way to keep your children learning and growing throughout the summer. The focus of Around the World In 30 Days Summer Enrichment Camp will include instructional and social/recreational enrichment activities. Parents will receive confirmation letters of the child’s assignment for summer school by June 1st. We look forward to an enjoyable and rewarding summer session. If you have any questions, you may contact Ms. Bush at 704-649.7262. Email: Zebuloninc@gmail.com Thank you,
Ms. Bush and Mr. Dany Student’s Name: ___________________ Grade:_________Age:______ Student’s Name: ___________________ Grade:_________Age:______ Student’s Name: ___________________ Grade:_________Age:______
Parents Name: _____________________________________________________________ Parents Name: _____________________________________________________________ Address: ___________________________________________________________________ Telephone: _______________________ Cell & Contact ____________________________
Emergency Information Form Student Name: ________________________________________ Mother’s Work Phone: ______________________ Father’s Work Phone:________________________ Responsible persons to call in case of illness or accident: 1. ________________________________________ Phone: _____________________ 2. ________________________________________ Phone: _____________________ Family Doctor: ______________________________ Phone: _____________________ Does Your Child Have Any Health Conditions/Allergies?
Yes____
No_____
What Conditions?___________________________________________________________ Does Your Child Have Any Food Allergies?
Yes____
No_____
What Conditions?___________________________________________________________
I, the undersigned do hereby authorize officials of the Around the World In 30 Days
Summer Enrichment Camp to contact the persons named on this form, and do authorize the named physician(s) to render such treatment as deemed necessary in an emergency, for the health and welfare of said child. In the event the physician(s) or other persons named on this form cannot be contacted, the camp personnel students will be transported to the nearest hospital, usually CMC that need to know the information for educational purposes and or to protect the life and safely of said child. I will not hold the camp responsible for the emergency care and/or transportation for said child. I understand that this form will be shared with all camp personnel that need to know the information for to protect the life and safety of said child. My child has permission to go on any field trips connected with the summer program. Yes____ No ____ I would be interested in being a parent volunteer. Yes___ No____ Information regarding development and achievement levels of your child will be sought from his or her current teacher to determine appropriate placement for the summer school session. We are also interested in knowing what your expectations as parents are for your child. Please take a few moments to write down what you are expecting your child to gain from summer school.
__________________________________________ Parent/Guardian Signature
________________________________ Date