camp adventure registration
CAMP ADVENTURE REGISTRATION Atlee Christian Academy 8391 Atlee Road, Mechanicsville, VA 23116 www.atleechristianacademy.com / 746-3900 Child:
Nickname:
Address:
City:
Date of Birth: Zip:
Sex:
Home Phone:
Chronic Physical Problems / Pertinent Development Information / Special Accommodations Needed:
Previous Child Day Care Programs and Schools Attended:
Child’s Current Age & Last Grade Completed:
PARENT(S) / GUARDIAN(S) Father:
Place of Employment:
Work Phone:
Full Address including City, State, & Zip:
Home Phone:
Email:
Mobile Phone:
Mother:
Place of Employment:
Work Phone:
Full Address including City, State, & Zip:
Home Phone:
Email:
Mobile Phone:
If applicable, please list the person(s) or Agency having legal custody of child:
Work Phone:
Full Address including City, State, & Zip:
Home Phone:
Church your family attends regularly:
Cell Phone:
EMERGENCY INFORMATION Allergies or Intolerance to Food, Medication, etc., and Action to Take in an Emergency: Child’s Physician:
Phone:
Two People To Contact if Parent(s) Cannot Be Reached: Address:
Phone:
1.
1.
1.
2.
2.
2.
Person(s) Authorized to Pick Up Child: *Person(s) NOT Authorized to Pick Up Child: *Appropriate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child. (over)
AGREEMENTS 1. 2.
I authorize the child care center to obtain immediate medical care if any emergency occurs when the parent/ guardian cannot be located immediately. ** I agree to comply with all matters covered in the ACA parent/student handbook.
SIGNATURES ________________________________________________________ Parent or Guardian
____________________ Date
________________________________________________________ Executive Director
____________________ Date
**If there is an objection to seeking emergency medical care, a statement should be obtained from the parent or guardian that states the objection and the reason for the objection.
Transportation Authorization My Child _____________________________ has my permission to be transported by Atlee Christian Academy Employees from June _____ to September _____ to participate in the off-campus fieldtrips.
Putt-Putt
Pocahontas State Park
Bowling The Dome Three Lakes Park Pole Green Park
These are just an example of the types of locations we are planning for the Summer, should other in-house or on-the-road trips be planned, or these location change, parents will be notified accordingly.
Spirited Art If there are any fieldtrips or activities you do not wish your child to participate in, Alternative childcare for the day of that activity / fieldtrip will need to be made.
Registration Fees Registration fees are non-refundable
Camp Adventure Summer Program Weekly Cost: $128 (for 5 day program) $95 (for 3 day program) $70 (for 2 day program) One Time Fees: $80 Registration fee $100 Activity Fee
Program I am interested in: _____ 5 Day Program _____ 3 Day Program Circle 3: M T W TH F _____ 2 Day Program Circle 2: M T W TH F
Nickname:
Address:
City:
Date of Birth: Zip:
Sex:
Home Phone:
Chronic Physical Problems / Pertinent Development Information / Special Accommodations Needed:
Previous Child Day Care Programs and Schools Attended:
Child’s Current Age & Last Grade Completed:
PARENT(S) / GUARDIAN(S) Father:
Place of Employment:
Work Phone:
Full Address including City, State, & Zip:
Home Phone:
Email:
Mobile Phone:
Mother:
Place of Employment:
Work Phone:
Full Address including City, State, & Zip:
Home Phone:
Email:
Mobile Phone:
If applicable, please list the person(s) or Agency having legal custody of child:
Work Phone:
Full Address including City, State, & Zip:
Home Phone:
Church your family attends regularly:
Cell Phone:
EMERGENCY INFORMATION Allergies or Intolerance to Food, Medication, etc., and Action to Take in an Emergency: Child’s Physician:
Phone:
Two People To Contact if Parent(s) Cannot Be Reached: Address:
Phone:
1.
1.
1.
2.
2.
2.
Person(s) Authorized to Pick Up Child: *Person(s) NOT Authorized to Pick Up Child: *Appropriate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child. (over)
AGREEMENTS 1. 2.
I authorize the child care center to obtain immediate medical care if any emergency occurs when the parent/ guardian cannot be located immediately. ** I agree to comply with all matters covered in the ACA parent/student handbook.
SIGNATURES ________________________________________________________ Parent or Guardian
____________________ Date
________________________________________________________ Executive Director
____________________ Date
**If there is an objection to seeking emergency medical care, a statement should be obtained from the parent or guardian that states the objection and the reason for the objection.
Transportation Authorization My Child _____________________________ has my permission to be transported by Atlee Christian Academy Employees from June _____ to September _____ to participate in the off-campus fieldtrips.
Putt-Putt
Pocahontas State Park
Bowling The Dome Three Lakes Park Pole Green Park
These are just an example of the types of locations we are planning for the Summer, should other in-house or on-the-road trips be planned, or these location change, parents will be notified accordingly.
Spirited Art If there are any fieldtrips or activities you do not wish your child to participate in, Alternative childcare for the day of that activity / fieldtrip will need to be made.
Registration Fees Registration fees are non-refundable
Camp Adventure Summer Program Weekly Cost: $128 (for 5 day program) $95 (for 3 day program) $70 (for 2 day program) One Time Fees: $80 Registration fee $100 Activity Fee
Program I am interested in: _____ 5 Day Program _____ 3 Day Program Circle 3: M T W TH F _____ 2 Day Program Circle 2: M T W TH F
