CampRegistration 2016

$250 non-refundable registration fee due upon enrollment. This is not a deposit or applied towards tuition.

This is a separate registration form and fee than our Fall 2015-2016 registration.

Child’s Name

LastFirstMiddleNickname

Date of Birth / / Sex:M/F Hebrew Name

Home Address Primary E-Mail ______

City ___State ______Zip ______Home Phone ______

I would like to enroll in:3 Days4 Days5 Days

Half Day 9:00-1:00Full Day 8:30-3:30Extended Day 7:00-6:30 Mon Tues Wed Mon Tues Wed Mon Tues Wed

Thurs FriThurs Fri Thurs Fri

____Week 1: June 21 – June 24 ____Week 6: July 25 – July 29

____Week 2: June 27 – July 1 ____Week 7: August 1 – August5

____Week 3: July4– July 8 ____Week 8: August 8 – August 12

____Week 4: July 11 – July 15 ____Week 9: August 15 – August 19

____Week 5: July 18 – July 22 ____ Entire Summer Camp

Additional Schedule Information or Special Requests: ______

Mother’s Information Father’s Information

Name Name

Address Address

City, State, Zip City, State, Zip

Occupation Occupation

Employer Employer

Business Phone Business Phone

Cell Phone Cell Phone

Email Email

Marital Status:Married Separated Divorced Marital Status: Married Separated Divorced Widowed Remarried  Other Widowed Remarried  Other

Please list any children who are currently enrolled or who have been enrolled with us

Where did you hear about our school? ______

Medical

Child’s Doctor Phone

Known Allergies

Does your child have any special needs we should be aware of? Please provide the school with your child’s IEP or IFSP, if applicable.

______

Emergency Contact Info: Persons authorized to pick up your child and/or contact in case of emergency if neither parents are available to assume responsibility for the child.

Name Relationship

Cell Phone Other Phone

Name Relationship

Cell Phone Other Phone

Custody

Please describe custody arrangement (if applicable.) If a non-custodial parent is NOT authorized by the custodial parent to pick up the child, please explain on separate document and attach a copy of appropriate court order.

Please list a person PROHIBITED from picking up child______

Parent(s) Signature

I (we) attest that all of the information we have supplied to Kol Chaverim is accurate.

I (we) have received the following information for my (our) home records, have read and understand them:

  1. Information to Parents Document
  2. Policy on the Release of Children
  3. Philosophy of Discipline
  4. Policy on the Management of Illness/Communicable Diseases
  5. Policy on the Expulsion of Students from Enrollment

I (we) authorize the center to seek emergency medical care for my child as deemed necessary by the director or the director’s designee.

I (we) give permission for my child to participate in walking trips within the center’s neighborhood.

I (we) give permission for my child’s photo to be posted on the school website and in newsletters.

I (we) have submitted the $250 registration fee with the registration form and understand that this fee does not apply towards tuition.

I (we) understand that our summer rates and scheduling options differ from our academic school year and that these payments must be made in full or in two separate installments prior to the entire nine week program.

*If applicable: I (we) understand that my June 2016 security deposit/payment does not cover the first week of camp tuition.

______

Parent’s Signature Parent’s Signature Date