Summer Day Camp Enrollment Form

Please select 1st time registering for 2018 to get started!*

1st time registering in 2018
Returning for additional week(s)

Child's Name*

First Last

Gender*

Male
Female

Address*

Street Address City State ZIP Code

Email*

(a copy of this form will be sent to this email)

Birth Date*

Grade in August 2018*

Father's Name*

First Last

Cell*

Work Phone

Occupation*

Company Name*

Mother's Name*

First Last

Cell*

Work Phone

Occupation*

Company Name*

Emergency Contact (parent unavailable)*

Relationship to Child*

Phone*

Member of Homenetmen Glendale "Ararat" Chapter*

Yes (active member with fully paid membership)
No

10% "member" discount is reflected in the total below.

Payment Options*

Pay in full now
Pay in person by check or cash

There will be an additional $15 for Wednesday Field Trips

Payment Options*

Pay in full now

There will be an additional $15 for Wednesday Field Trips

Week 1

June 11-June 15

2 Days ($150)
3 Days ($200)
4-5 Days ($250)
Not Selected

Please select which days the child will attend*

June 11
June 12
June 13
June 14
June 15

Please select which days the child will attend*

June 11
June 12
June 13
June 14
June 15

Week 2

June 18-June 22

2 Days ($150)
3 Days ($200)
4-5 Days ($250)
Not Selected

Please select which days the child will attend*

June 18
June 19
June 20
June 21
June 22

Please select which days the child will attend*

June 18
June 19
June 20
June 21
June 22

Week 3

June 25-June 29

2 Days ($150)
3 Days ($200)
4-5 Days ($250)
Not Selected

Please select which days the child will attend*

June 25
June 26
June 27
June 28
June 29

Please select which days the child will attend*

June 25
June 26
June 27
June 28
June 29

NO CAMP 4th of July Week: July 2-July 6

Week 4

July 9-June 13

2 Days ($150)
3 Days ($200)
4-5 Days ($250)
Not Selected

Please select which days the child will attend*

July 9
July 10
July 11
July 12
July 13

Please select which days the child will attend*

July 9
July 10
July 11
July 12
July 13

Week 5

July 16-July 20

2 Days ($150)
3 Days ($200)
4-5 Days ($250)
Not Selected

Please select which days the child will attend*

July 16
July 17
July 18
July 19
July 20

Please select which days the child will attend*

July 16
July 17
July 18
July 19
July 20

Week 6

July 23-July 27

2 Days ($150)
3 Days ($200)
4-5 Days ($250)
Not Selected

Please select which days the child will attend*

July 23
July 24
July 25
July 26
July 27

Please select which days the child will attend*

July 23
July 24
July 25
July 26
July 27

Week 7

July 30-August 3

2 Days ($150)
3 Days ($200)
4-5 Days ($250)
Not Selected

Please select which days the child will attend*

July 30
July 31
August 1
August 2
August 3

Please select which days the child will attend*

July 30
July 31
August 1
August 2
August 3

Week 8

August 6- August 10

2 Days ($150)
3 Days ($200)
4-5 Days ($250)
Not Selected

Please select which days the child will attend*

August 6
August 7
August 8
August 9
August 10

Please select which days the child will attend*

August 6
August 7
August 8
August 9
August 10

Week 9

August 13- August 17

2 Days ($150)
3 Days ($200)
4-5 Days ($250)
Not Selected

Please select which days the child will attend*

August 13
August 14
August 15
August 16
August 17

Please select which days the child will attend*

August 13
August 14
August 15
August 16
August 17

FULL PAYMENT FOR THE WEEK IS DUE BY FRIDAY OF THE PREVIOUS WEEK. If deadline is not respected, there will be a $20 late fee.
I understand that there are no credits for missed days and I understand the cancellation policy (See Terms and Conditions)
Rates include: care from 7:30 am to 5:30 pm, breakfast, lunch, snacks and most fieldtrips.

ADDITIONAL FIELD TRIP FEES WILL BE STATED ON THE PARENT LETTER AND COLLECTED THE WEEK OF YOUR CHILD’S ATTENDANCE.
There is an additional $5 fee for every additional 15 minutes that a parent is late to pick up their child. This fee must be paid upon picking the child up.

Applicants that wish to attend only two or three days a week cannot start the week on Wednesday.

Non-Member Total for 1st Child

Price: $0.00

Member Total for 1st Child

Price: $0.00

PARENT CONSENT

Name*

Relationship with child*

Mother
Father
Guardian

Child's name*

*

Agrees and authorize to the following

Tylenol Consent:*

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

Water Play

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

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

Date*

I hereby authorize my child to be picked-up from Summer Day Camp Activities in my absence by:

Name

Relationship to Child

Name

Relationship to Child

Name

Relationship to Child

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 our child in case of illness or accident when neither parent can be located.*

(Child’s Name)

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

Second Child Registration

Would you like to register for your second child?*

Yes
No

Second Child's Name*

First Last

Gender*

Male
Female

Birth Date*

Grade in August 2017*

Member of Homenetmen Glendale "Ararat" Chapter*

Yes
No

Summer Day Camp Second Child

Week 1

June 11-June 15

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

June 11
June 12
June 13
June 14
June 15

Please select which days the child will attend*

June 11
June 12
June 13
June 14
June 15

Week 2

June 18-June 22

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

June 18
June 19
June 20
June 21
June 22

Please select which days the child will attend*

June 18
June 19
June 20
June 21
June 22

Week 3

June 25-June 29

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

June 25
June 26
June 27
June 28
June 29

Please select which days the child will attend*

June 25
June 26
June 27
June 28
June 29

NO CAMP 4th of July Week: July 2-July 6

Week 4

July 9-July 13

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

July 9
July 10
July 11
July 12
July 13

Please select which days the child will attend*

July 9
July 10
July 11
July 12
July 13

Week 5

July 16-July 20

2 Days ($135)
3 Days ($180)
Not Selected

Please select which days the child will attend*

July 16
July 17
July 18
July 19
July 20

Please select which days the child will attend*

July 16
July 17
July 18
July 19
July 20

Week 6

July 23-July 27

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

July 23
July 24
July 25
July 26
July 27

Please select which days the child will attend*

July 23
July 24
July 25
July 26
July 27

Week 7

July 30-August 3

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

July 30
July 31
August 1
August 2
August 3

Please select which days the child will attend*

July 30
July 31
August 1
August 2
August 3

Week 8

August 6- August 10

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

August 6
August 7
August 8
August 9
August 10

Please select which days the child will attend*

August 6
August 7
August 8
August 9
August 10

Week 9

August 13-August 17

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

August 13
August 14
August 15
August 16
August 17

Please select which days the child will attend*

August 13
August 14
August 15
August 16
August 17

PARENT CONSENT

Name*

Relationship with child*

Mother
Father
Guardian

Child's name*

*

Agrees and authorize to the following

Tylenol Consent:*

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

Water Play

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

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

CONSENT FOR MEDICAL TREATMENT FOR YOUR SECOND CHILD

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 our child in case of illness or accident when neither parent can be located.*

(Second Child’s Name)

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

Third Child Registration

Would you like to register for your third child?*

Yes
No

Third Child's Name*

First Last

Gender*

Male
Female

Birth Date*

Grade in August 2017*

Member of Homenetmen Glendale "Ararat" Chapter*

Yes
No

Summer Day Camp Third Child

Week 1

June 11-June 15

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

June 11
June 12
June 13
June 14
June 15

Please select which days the child will attend*

June 11
June 12
June 13
June 14
June 15

Week 2

June 18-June 22

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

June 18
June 19
June 20
June 21
June 22

Please select which days the child will attend*

June 18
June 19
June 20
June 21
June 22

Week 3

June 25-June 29

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

June 25
June 26
June 27
June 28
June 29

Please select which days the child will attend*

June 25
June 26
June 27
June 28
June 29

NO CAMP 4th of July Week: July 2-July 6

Week 4

July 9-July 13

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

July 9
July 10
July 11
July 12
July 13

Please select which days the child will attend*

July 9
July 10
July 11
July 12
July 13

Week 5

July 16-July 20

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

July 16
July 17
July 18
July 19
July 20

Please select which days the child will attend*

July 16
July 17
July 18
July 19
July 20

Week 6

July 23-July 27

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

July 23
July 24
July 25
July 26
July 27

Please select which days the child will attend*

July 23
July 24
July 25
July 26
July 27

Week 7

July 30-August 3

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

July 30
July 31
August 1
August 2
August 3

Please select which days the child will attend*

July 30
July 31
August 1
August 2
August 3

Week 8

August 6-August 10

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

August 6
August 7
August 8
August 9
August 10

Please select which days the child will attend*

August 6
August 7
August 8
August 9
August 10

Week 9

August 13-August 17

2 Days ($135)
3 Days ($180)
4-5 Days ($225)
Not Selected

Please select which days the child will attend*

August 13
August 14
August 15
August 16
August 17

Please select which days the child will attend*

August 13
August 14
August 15
August 16
August 17

PARENT CONSENT

Name*

Relationship with child*

Mother
Father
Guardian

Child's name*

*

Agrees and authorize to the following

Tylenol Consent:*

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

Water Play

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

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

CONSENT FOR MEDICAL TREATMENT FOR YOUR THIRD CHILD

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 our child in case of illness or accident when neither parent can be located.*

(Third Child’s Name)

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

Payment Info

Billing Address*

Street Address City State ZIP Code

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Grand Total

$0.00

Terms & Conditions*

I agree to the terms and conditions of Ararat Summer Day Camp. (click to view)

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.

Enter Name (same as your signature)*

Date*