Ararat.org | Homenetmen Glendale "Ararat" Chapter


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Summer Day Camp Enrollment Form

3347 N. San Fernando Rd.
Los Angeles, CA 90065
Tel: (323) 256-2564 | Fax: (323) 256-0639
Web: www.ararat.org | E-mail: info@ararat.org
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* - required fields (if a field does not apply, enter N/A)

Does you Child have allergies? *

Week
Date
2 Days
3 Days
4-5 Days
Not Selected
Week 1*
7/5-7/8
Week 2
7/11-7/15
Week 3
7/18-7/22
Week 4
7/25-7/29
Week 5
8/1-8/5
Week 6
8/8-8/12
Week 7
8/15-8/19
Week 8
8/22-8/26
+ $10.00 (T-shirt fee) =

* - 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.

(You will be able to pay this online after you submit your application.)

   

T-Shirt size: *

- a copy of this form will be sent to this email

Child lives with: *

Are you able to volunteer on Wednesdays for our field trips: *

Member of Homenetmen Glendale "Ararat" Chapter: *

I learned about Camp from: *

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? *

 

PARENT CONSENT

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

Tylenol Consent: Administer Tylenol: *

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. *

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. *

Water Play:

I authorize my child to participate in supervised water play activities.