Summer Learning & Fun Camp Fill out the form below to register: Summer Learning & Fun Camp Registration FormChildNumber of Children AttendingNumber of Children AttendingAdditional ChildrenPlease Add Additional Children HereFirst NameMiddle NameLast NameGenderSchool NameGradeBirth DateAgeYouth SizeAdult Size Name First Middle Last GenderGender Male Female Address Street Address Town/City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip code Child’s Home PhoneParent/Guardian - Contact InformationParent/Guardian #1Name First Last Ms.Mrs.Mr.Address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmail Occupation Employer Parent/Guardian #2Name First Last Ms.Mrs.Mr.Address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneDaytime PhoneCell PhoneEmail Occupation Employer Child lives with: Person responsible for payment Please list those people including in addition to parents/guardians who are permitted to pick up your child:Please list those people including in addition to parents/guardians who are permitted to pick up your child: Please list anyone who ARE NOT permitted to pick up your child:Please list anyone who ARE NOT permitted to pick up your child: The purpose of the below listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment. Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures) Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures)Does child have any medical and/or psychiatric history?Does child have any medical and/or psychiatric history?NoYesMedical informationMedical informationAdditional informationAdditional information(allergies to insects, food, and/or medication; any special diet)Should the paramedics be called?Should the paramedics be called?NoYesThe purpose of the below listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.In case of medical emergency contact:In case of medical emergency contact:NamePhoneRelationship to Child I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. I understand that The Grandma Home House Retreat will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.Parent’s/Guardian’s Initials:Parent’s/Guardian’s Initials:TUITION INFORMATION - $225 per weekly session Tuition QuantityTuition Price: Please mark one or more sessions:Please mark one or more sessions: Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Coupon Code TotalTotal $0.00 *Please note that lunch will not be provided, but snacks will be available for sale daily.Please check how you heard about The Grandma Home House Retreat Summer Learning & Fun Camp.Please check how you heard about The Grandma Home House Retreat Summer Learning & Fun Camp. Facebook Website Word of Mouth Flyer Terms of Agreement Photo Release I hereby give permission for my child to be photographed during The Grandma Home House Retreat Summer Learning & Fun Camp. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of The Grandma Home House Retreat and its affiliates.Parent’s/Guardian’s Initials:Parent’s/Guardian’s Initials:Terms of Agreement The Grandma Home House Retreat is not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Children's’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).Guardian Signature:Guardian Signature:DateDate Day Month Year Printed Name of Parent/Guardian:
