Camp $800 + Extended Hours fees Early Reg. $600 + Extended ...
For Provider Use Only:
Date of Admission ______________
Date of Discharge ______________
CHILD INFORMATION
PARENT INFORMATION (Also used as
Child: ______________________________________
Emergency Contact and Release of child)
Please mark the weeks that your child will be attending camp & extended hours
Mother: ________________________________________
Week 1 June 19-23
Week 4 July 10-14
Week 7 July 31-Aug. 4
O AM Extended Hours
O AM Extended Hours
O AM Extended Hours
Grade in Fall: _______ DOB: ___________ M/F
Phone:
O PM Extended Hours
O PM Extended Hours
O PM Extended Hours
Week 5 July 17-21
Week 8 Aug. 7-11
School: ___________________________
(C/H)_______________________________
Week 2 June 26-30 O AM Extended Hours
O AM Extended Hours
O AM Extended Hours
(W) ________________________________
O PM Extended Hours
O PM Extended Hours
O PM Extended Hours
Home Address: ________________________________________
Week 3 July 3-7
Week 6 July 24-July 28
O AM Extended Hours
O AM Extended Hours
O PM Extended Hours
O PM Extended Hours
Age: ________
Home Address: ________________________________________ City: _________________________Zip: _______ Physician/Health Clinic:
City: _________________________Zip: _______
________________________________________
Employer: _______________________________
Physician/Health Clinic Phone:
Father: ________________________________________
________________________
Phone: (C/H)_______________________________
Email: (Please print clearly)
(W) ________________________________
Mother: __________________________________
Home Address: ________________________________________
Father: ___________________________________
City: _________________________Zip: _______ Employer: _______________________________
T-SHIRT SIZE Child Size:
Small (6/8)
Medium (10/12)
Adult Size:
Small
Medium
Large (14/16) Large
Extra-Large
Please make sure you order the proper size. When in doubt, order a larger size! Parents will be charged for any additional shirts that need to be ordered due to an error in size.
(No camp on July 4th)
Camp $800 + Extended Hours fees Early Reg. $600 + Extended Hours AM Extended Hours (8am-9am) $25 per week due at the beginning of each week PM Extended Hours (4pm-6pm) $25 per week due at the beginning of each week
Note: All registration forms must have the nonrefundable $25 registration fee included before being accepted into the program. The remaining amount must be paid no later than Friday, May 26, 2017 in order for your child to be accepted into camp. You must register in person. *Refund Policy: There is a 100% refund (not including the registration fee) prior to May 26.
RELEASE INFORMATION
Medication: __________________________________________________
____Activity Release: The above named child has my permission to attend the Summer Programs
Times Taken: ________________________________________________
at The SAL, which is sponsored by The Salvation Army in Grand Rapids, MI. They are free to
Allergies/Special Needs/Special Instructions:
participate in all the outlined activities, as well as, all of the offsite activities which are provided
_____________________________________________________________
through day camp each week. It is agreed that I do not hold The Salvation Army responsible for negligence on the part of my child during any aspect of the summer program. I understand that my
Swim Level:
Beginner
Intermediate
Advanced
child is protected by The Salvation Army’s insurance coverage, provided the injury occurs between the regular hours of the program and that The Salvation Army or an outside organization is liable for the negligence.
In Case of an Emergency, if parent cannot be reached, please contact:
____Photo Release: In the event that The SAL would wish to use a photo of my child in
(Also used as Release of Child)
publications & websites, my permission is granted.
1)Name: ____________________________________________________
____ Emergency Medical Care: In the event that a parent or the emergency contact cannot be
Phone: _____________________________________________________
reached, The SAL Community Center has my permission to secure emergency medical treatment for
2)Name: ____________________________________________________
the above named child. NON-EMERGENCY treatment is not included in this release.
Phone: _____________________________________________________
____ Prescription Medication: In the event that prescription medication is to be administered, the SAL Community Center may administer medication as specified in written instructions.
Initial the above to which you agree and sign here Parent Signature: ____________________________________________ Date: _____________
CAMPER AGREEMENT I promise to do my best to make good choices while I am a camper at The SAL. I will obey the rules and respect all other campers and leaders. I understand that if I break the rules or show disrespect to others, my participation in the day camp could be terminated. I sign this agreement on my honor.
Camper Signature:__________________________________________________________
3)Name: ____________________________________________________ Phone: _____________________________________________________ 4)Name: ____________________________________________________ Phone: _____________________________________________________
FOR OFFICE USE ONLY Deposit Paid Date:______________ Amnt. Pd._____________ Receipt #________________ Balance Due________________ Check #_________________ Extended Hours Fees: _____________ Final Pmnt Date:______________ Amnt. Pd.______________ Receipt #____________________ Check#________________
Date of Admission ______________
Date of Discharge ______________
CHILD INFORMATION
PARENT INFORMATION (Also used as
Child: ______________________________________
Emergency Contact and Release of child)
Please mark the weeks that your child will be attending camp & extended hours
Mother: ________________________________________
Week 1 June 19-23
Week 4 July 10-14
Week 7 July 31-Aug. 4
O AM Extended Hours
O AM Extended Hours
O AM Extended Hours
Grade in Fall: _______ DOB: ___________ M/F
Phone:
O PM Extended Hours
O PM Extended Hours
O PM Extended Hours
Week 5 July 17-21
Week 8 Aug. 7-11
School: ___________________________
(C/H)_______________________________
Week 2 June 26-30 O AM Extended Hours
O AM Extended Hours
O AM Extended Hours
(W) ________________________________
O PM Extended Hours
O PM Extended Hours
O PM Extended Hours
Home Address: ________________________________________
Week 3 July 3-7
Week 6 July 24-July 28
O AM Extended Hours
O AM Extended Hours
O PM Extended Hours
O PM Extended Hours
Age: ________
Home Address: ________________________________________ City: _________________________Zip: _______ Physician/Health Clinic:
City: _________________________Zip: _______
________________________________________
Employer: _______________________________
Physician/Health Clinic Phone:
Father: ________________________________________
________________________
Phone: (C/H)_______________________________
Email: (Please print clearly)
(W) ________________________________
Mother: __________________________________
Home Address: ________________________________________
Father: ___________________________________
City: _________________________Zip: _______ Employer: _______________________________
T-SHIRT SIZE Child Size:
Small (6/8)
Medium (10/12)
Adult Size:
Small
Medium
Large (14/16) Large
Extra-Large
Please make sure you order the proper size. When in doubt, order a larger size! Parents will be charged for any additional shirts that need to be ordered due to an error in size.
(No camp on July 4th)
Camp $800 + Extended Hours fees Early Reg. $600 + Extended Hours AM Extended Hours (8am-9am) $25 per week due at the beginning of each week PM Extended Hours (4pm-6pm) $25 per week due at the beginning of each week
Note: All registration forms must have the nonrefundable $25 registration fee included before being accepted into the program. The remaining amount must be paid no later than Friday, May 26, 2017 in order for your child to be accepted into camp. You must register in person. *Refund Policy: There is a 100% refund (not including the registration fee) prior to May 26.
RELEASE INFORMATION
Medication: __________________________________________________
____Activity Release: The above named child has my permission to attend the Summer Programs
Times Taken: ________________________________________________
at The SAL, which is sponsored by The Salvation Army in Grand Rapids, MI. They are free to
Allergies/Special Needs/Special Instructions:
participate in all the outlined activities, as well as, all of the offsite activities which are provided
_____________________________________________________________
through day camp each week. It is agreed that I do not hold The Salvation Army responsible for negligence on the part of my child during any aspect of the summer program. I understand that my
Swim Level:
Beginner
Intermediate
Advanced
child is protected by The Salvation Army’s insurance coverage, provided the injury occurs between the regular hours of the program and that The Salvation Army or an outside organization is liable for the negligence.
In Case of an Emergency, if parent cannot be reached, please contact:
____Photo Release: In the event that The SAL would wish to use a photo of my child in
(Also used as Release of Child)
publications & websites, my permission is granted.
1)Name: ____________________________________________________
____ Emergency Medical Care: In the event that a parent or the emergency contact cannot be
Phone: _____________________________________________________
reached, The SAL Community Center has my permission to secure emergency medical treatment for
2)Name: ____________________________________________________
the above named child. NON-EMERGENCY treatment is not included in this release.
Phone: _____________________________________________________
____ Prescription Medication: In the event that prescription medication is to be administered, the SAL Community Center may administer medication as specified in written instructions.
Initial the above to which you agree and sign here Parent Signature: ____________________________________________ Date: _____________
CAMPER AGREEMENT I promise to do my best to make good choices while I am a camper at The SAL. I will obey the rules and respect all other campers and leaders. I understand that if I break the rules or show disrespect to others, my participation in the day camp could be terminated. I sign this agreement on my honor.
Camper Signature:__________________________________________________________
3)Name: ____________________________________________________ Phone: _____________________________________________________ 4)Name: ____________________________________________________ Phone: _____________________________________________________
FOR OFFICE USE ONLY Deposit Paid Date:______________ Amnt. Pd._____________ Receipt #________________ Balance Due________________ Check #_________________ Extended Hours Fees: _____________ Final Pmnt Date:______________ Amnt. Pd.______________ Receipt #____________________ Check#________________
