Out of the Box Summer Enrichment Camp

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Child’s Information
Last Name: / First Name: / Nickname:
Date of Birth: / Age: / Gender:F M / Grade Entering:
Does child have an IEP?
Yes No / Is child in ELL/ESOL Program?
Yes No / Is child in Gifted Program?
Yes No
Allergies: / Medical Conditions:
T-Shirt Size:
YXS(2-4) YS(6-8) YM(10-12) YL(14-16) / T-Shirt Size(additional child):
YXS(2-4) YS(6-8) YM(10-12) YL(14-16)
Parent/GuardianInformation
Last Name:
/ First Name: / Relationship:
Address:
City: / State: / Zip:
Home Phone: / Cell Phone: / Work Phone:
Email:
Last Name:
/ First Name: / Relationship:
Address:
City: / State: / Zip:
Home Phone: / Cell Phone: / Work Phone:
Email:
Child’s Living Arrangements (check one): Both Parents Mother Father Other
Child’s Legal Guardian (check one): Both Parents Mother Father Other
The child may be released to the person(s) signing this document or to the following:
Last Name: / First Name: / Relationship: / Phone:
Last Name: / First Name: / Relationship: / Phone:
Emergency Contact Information
Last Name: / First Name: / Relationship: / Phone:
Last Name: / First Name: / Relationship: / Phone:
Emergency Medical Release
Primary Care Physician: / Phone:
Health Insurance: / Policy # /Group #:

Attendance:

I understand that the summer camp is a 5-week program and that my child must attend 4 out of the 5 weeks of the academic program. I also understand that if I pull my child out of the program, I am still responsible for the tuition.

Signature of Parent/Guardian

Permission & Liability Waiver:

My child, ______, has permission to fully participate in Educationally Speaking Center for Learning activities. I, as parent/legal guardian, do hereby grant the Educationally Speaking Center for Learning staff and designated adults the right to authorize emergency medical treatment for my child in the event that I, or my designated representative, cannot be reached. I agree to hold harmless Educationally Speaking Center for Learning and its agents from liability resulting from an accident. The Georgia Good Samaritan Law will apply.

I hereby grant permission for staff to take whatever steps may be necessary to obtain emergency treatment for my child. These steps may include, but are not limited to, the following:

1. In a life-threatening emergency or urgent situation, staff will call 911 before making any attempt to contact

parents.

2. For non-life-threatening emergency, we will attempt to call the parent/guardian first, and if we cannot reach

them, we will attempt to contact the emergency contacts listed. If we cannot make an appropriate contact,

we will call paramedics or the child’s health care provider.

______

Signature of Parent/Guardian Date Signature Parent/Guardian Date

______

Print Name Parent/Guardian Print Name Parent/Guardian