Indulgence Summer Camp Registration 2019

Indulgence Summer Camp Registration 2019
Camper Information
Camper's Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Camper's Mobile Number

Area CodePhone Number
Sex*

MaleFemale
Date of Birth*

MonthDayYear
Date
Age*
Number
Grade entering for 19/20 school year*
Names of Siblings Attending Camp
Primary Guardian Name*

First NameLast Name
Primary Home #

Area CodePhone Number
Primary Work #

Area CodePhone Number
Primary Mobile #*

Area CodePhone Number
Primary Email Address
example@example.com
Secondary Guardian Name

First NameLast Name
Secondary Home #

Area CodePhone Number
Secondary Work #

Area CodePhone Number
Secondary Mobile #

Area CodePhone Number
Secondary Email Address
example@example.com
Legal Custody of Child*

Both ParentsMotherFather
Can anyone else pick up child?*

YesNo

If yes, please complete the information below:

	Full Name	Relationship	Home Phone#	Work Phone #	Cell Phone #
1.
2.
3.

Camp Fees
Required Fees:
►$25.00 ~ Non-Refundable Registration Fee
►$40.00 ~ Per Camper, Per Week
►$14.00 ~ Camp T-shirts
Optional Fees
►$200.00 ~ Field trips
►Before care 6am-8am: $5.00 Per CamperWeek
►Aftercare 5pm-6pm: $5.00 Per CamperWeek
►Extended Care AM/PM: $10.00 Per CamperWeek
Please list your child’s start date and end date for our Summer Camp program below. Also, for each Summer Camp week posted below, please mark which weeks child will be attending. As a reminder, if your child is absent for an entire week, you must provide two weeks' notice in writing.
• Summer Camp starts: Monday, June 3rd and ends Friday, August 9th
• Drop-off: by 9:00 am
Summer Camp Start Date*

MonthDayYear
Date
Summer Camp End Date*

MonthDayYear
Date
Summer Camp Weeks (mark the weeks attending for each week listed below):*

June 3rd - 7thJune 10th - 14thJune 17th - 21stJune 24th - 28thJuly 1st - 3rd (Closed July 4th and July 5th)July 8th - 12thJuly 15th - 19thJuly 22nd - 26thJuly 29th August 2ndAugust 5th - 9th ( No afternoon extended care August 9th)
Signature Required

Clear
Release and Indemnification Agreement (Mandatory)
The parties to this agreement between parent/guardian for camper, and the Indulgence Company Inc (Indulgence Summer Camp), entering into this Agreement on behalf of the Child with the Camp and, as such, acknowledges and agrees that the Child shall be subject to all the rules and regulations of the Camp, as such are promulgated from time to time, whether upon the Camp premises or off the Camp premises on field trips, excursions and outings.

The parties agree that the Camp shall supervise and manage the Child (including during field trips, excursions, and outings), and that the Camp shall utilize ordinary care regarding the same. In return, Parent agrees that he/she shall not institute a suit in equity or in law, or both, resulting from or related to any loss, damage, injury or the like arising from circumstances which are not within the reasonable control of the Camp or resulting from the Child’s failure to abide by the Camp’s rules and regulations, particularly as same apply to violations of the Camp Code of Conduct by the Child.

Parent further agrees that he/she shall indemnify and hold harmless the Camp, its parent company, personal representatives, successors, assigns, officers, agents, volunteers, and employees, from any claim for any loss, damage or injury incurred as the result of the Child’s failure to abide by the Camp’s rules and regulations, particularly as same apply to violations of the Camp Code of Conduct by the Child.

Parent agrees that this Agreement shall inure to the benefit of the Camp, its parent company, agents, servants, volunteers, employees, and independent contractors and shall bind Parent, and Parent Spouse, heirs and legal representatives, if any.
Signature Required

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Medical Treatment Authorization

(Mandatory)
Parent's Name*

First NameLast Name
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Mobile Phone*

Area CodePhone Number
Child's Name*

First NameLast Name
Age*
Number
Date of Birth*

MonthDayYear
Date

If yes, please complete the information below:

	Full Name	Relationship	Phone Number
Emergency Contact
Emergency Contact
Emergency Contact

Family Doctor

First NameLast Name
Family Doctor Phone Number

Area CodePhone Number
Insurance Company
Policy/ID#
Does this child have any allergies, diseases, disabilities, or medical history the camp should be aware of in case of emergency?*

YesNo
If Yes, please explain:
Is the child on any medication(s)?*

YesNo
If Yes, please explain:
I give my permission to authorize treatment for my child, in case of emergency, illness or injury until I can be contacted. This notice is effective from he enrollment date until the child's withdrawal date.*

I allowI do not allow
I give my permission to administer Tylenol or its generic as s/he requests for headache or other pain.*

I allowI do not allow
Please state any limitations to the previous statements in the space below.
Signature Required

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Camper Code of Conduct
In order to maintain a safe and peaceful camp environment we require parents and campers to read and comprehend the importance of abiding by the following code of conduct:

I will follow the camp schedule. I will bring only listed and approved items to camp. I understand weapons of any kind, electronics, non-prescription drugs, and other items which can violate a safe, peaceful camp environment are not allowed. I will respect counselors, directors, and other campers by not using foul language, name calling, or fighting. I will follow all safety rules set forth by the camp staff.
Camper Name*

First NameLast Name
I agree to help my child abide by this code of conduct
Signature Required

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Authorizations & Policies

Please Initial All
PARENTAL PERMISSION FOR PHOTOGRAPHY AND VIDEO USE I grant Indulgence Summer Camp permission to use my son/daughter’s picture for promotion of the camp, whether in newspapers, newsletters, camp promotions or for teaching purposes.*
PARENTAL CONSENT AND PERMISSION TO LEAVE PROPERTY FOR FIELD TRIPS (ALL AGES) I grant my child permission to leave the Indulgence Summer Camp property for field trips which correlate to the camp lessons. I understand my child will be under supervision by camp staff and is expected to comply with all rules of the camp and any destination. My child has permission to be transported to and from camp field trips by the camp providers.*
EARLY ARRIVAL/LATE PICK UP FEES I havebeen informed of Indulgence Summer Camp schedules. I understand that IndulgenceSummer Camp fees do not include any before or after care and if I havenot enrolled my camper in extended care and they arrive early (before 8 am) orare picked up late (after 5:00pm) I will be assessed and agree to pay any feesapplicable to providing extended care*
PERMISSION TO RIDE:I (We) hereby grant permission for said child to ride in our vans or paid bus to any field trips or off-site outing.*
MEDICAL TREATMENT: Iauthorize school representatives to obtain medical treatment for mychild in case of serious illness or injuryand agree to pay for such treatment.I have noted any andall special health-related conditions, diagnoses, and/or allergiesregarding my child.*
PARENTS AGREEMENT TO PAY: I am responsible for making weekly tuition payments as set forth by Indulgence Summer Camp. Payments are due on Monday of each week and become delinquent Monday close of business. A $10.00 late fee will be assessed each day of the week Until fee is paid. If fee is not paid by the Friday of the same week, camper will not be allowed to attend camp. Payments are accepted in the form of cash, check,Debit, VISA or MasterCard only.*
HOLIDAYS: Our center will be closed July 4th and July 5th. We will not be having extended care on the last day of camp August 9th *
PHOTOGRAPH RELEASE FORM: the parent/guardian listed below, authorize Indulgence Summer Camp to photograph and video my child named below. I understand that these photographs may be used for public/iCamp Website display and/or advertising purposes. I give consent to have my child's photograph taken. *
WITHDRAWAL: A two-week notice is required when withdrawing from our summer camp or to make changes to summer camp weeks selected to attend. *
I am aware and agree to the following GENERAL POLICIES: *Tuition and Pick-up Policy, Absences and Payment Policy, Behavior *

Camp Enrollment Contract

Signature Mandatory
Both parents, guardians, or other persons responsible for payments should read all the provisions of this Contract, complete the required information, sign and return the Contract to the camp office accompanied by a non-refundable registration fee of $25. A student is accepted for enrollment when the Contract has been delivered to Indulgence Summer Camp. No amendment to this Contract and no alteration or addition to the printed terms hereof will be effective without the express prior written approval of the Camp Administrator.

In consideration of the acceptance of this Contract by Indulgence Summer Camp, the undersigned agrees to pay the required TOTAL CAMP COST AND FEES and agrees to be bound by the provisions of this Contract. So long as cost and fee payments are not delinquent, camp payments are due no later than the first day of camp. Enrollment in camp is conditioned upon the following terms:

1. A non-refundable registration fee of $25

2.   Students not enrolled in extended care must be dropped off no earlier than 8am and picked up no later than 5:00pm or additional fees for extended care will be assessed.

3.   Campers that will not be attending for a week or weeks must submit a 2-week notice advising

4.   Half of field trip fees must be paid the first day of summer camp on top of weekly tuition ($100)

5.   By my signature below I am agreeing to the provisions required for my child to enroll.
Signature Required

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Should be Empty:

Indulgence Summer Camp Registration 2019

Camper Information

Camp Fees

Release and Indemnification Agreement (Mandatory)

Medical Treatment Authorization

Camper Code of Conduct

Authorizations & Policies

Camp Enrollment Contract