Summer Day Camp Enrollment Form

* - required fields (if a field does not apply, enter N/A)

Does you Child have allergies? * Yes No (Please describe)

* - Special Rate due to short week

A Deposit of $100.00/week must be sent with the application in order to save a spot for your children.

$100 x * = * (You will be able to pay this online after you submit your application.)

T-Shirt size: * Youth S (6-8) Youth M (10-12) Youth L (14-16) Adult S Adult M Adult L

E-mail Address: * - a copy of this form will be sent to this email

Child lives with: * Mother Father Both Guardian

Are you able to volunteer on Wednesdays for our field trips: * Yes No

Member of Homenetmen Glendale "Ararat" Chapter: * Yes No

I learned about Camp from: * Friend Website Camp Flyer School Other

Registration processed in order received. $100.00 non refundable deposit per week or Full Payment REQUIRED when turning this form in. Please check the weeks you wish your child to attend. Rates include: care from 7:30 am to 6:00 pm, breakfast, lunch, snacks and most fieldtrips. FULL PAYMENT FOR THE WEEK IS DUE BY FRIDAY OF THE PREVIOUS WEEK. By signing below, I agree to the terms and conditions of Ararat Summer Day Camp. I understand that there are no credits for missed days and I understand the cancellation policy. The deposit is applicable to the total cost of the week and will be deducted from the total weekly fee for full payment. As the parent or legal guardian, I hereby give Ararat Summer Day Camp my consent and permission to take my child from the center on Field Trips. As the parent or legal guardian, I have signed and completed a full enrollment form for my child. I certify that all my information is accurate and correct including address, phone numbers, and persons authorized to pick-up my child, etc.

CONSENT FOR MEDICAL TREATMENT

As the parent/legal guardian, I hereby give consent to HOMENETMEN GLENDALE "ARARAT" CHAPTER to seek all emergency dental or medical care prescribed by duly licensed physician (M.D.) or dentist (D.D.S.) for * in case of illness or accident when neither parent can be located.

This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my dependent.

Child has the following medication/food allergies:

PHYSICIAN OR DENTIST TO BE CALLED IN EMERGENCY

Physician/Dentist:
Address:
Medical Plan and No:
Telephone:

Physician/Dentist:
Address:
Medical Plan and No:
Telephone:

If Physician cannot be reached, what action should be taken? *

Call Emergency Hospital Other Explain

PARENT CONSENT

I, * * Mother Father Guardian of * (Child’s Name) agrees and authorize to the following:

Tylenol Consent: Administer Tylenol: * Yes No

Field Trips & In-House Educational Programs:

I authorize my child to participate in any field trips & in-house educational programs organized by Homenetmen Glendale "Ararat" Chapter. * Yes No

Photographs & Videos:

I authorize Ararat to photograph and video tape my child during his/her camp activities and release these photos and videos to public broadcasting networks or any educational organization for Summer Day Camp introduction purposes. * Yes No

Water Play:

I authorize my child to participate in supervised water play activities. * Yes No