Summer Camp Registration Form

Please adjust the quantity according to how many sessions you are signing up for:

Sprouts (3-4 years old)$475

Blossoms (5-6 years old)$615

Select the sessions you would like to regester for:

Session 1: July 8-10 & July 15-17 (Sprouts) or July 8-11 & July 15-18 (Blossoms)

Session 2: July 22-24 & July 29-31 (Sprouts) or July 22-25 & July 29-August 1 (Blossoms)

Session 3: August 5-7 & August 12-14 (Sprouts) or August 5-8 & August 12-15 (Blossoms)

Participant First name

Participant Last name

PARTICIPANT AGE BY JUNE 1ST

Has your child been away from you before? Please share details, how do they manage separation?

Parent Name (1)

Address (1)

Primary Phone Number (1)

Parent Email (1)

Parent Name (2)

Address (2)

Primary Phone Number (2)

Parent Email (2)

Family Physician

Physician Phone Number

Emergency Contact (1)

Emergency Contact (1) Phone Number

Relationship to child

Can this person pick up participant?

Yes

Emergency Contact (2)

Emergency Contact (2) Phone Number

Relationship to child

Can this person pick up participant?

Yes

Please list any allergies your child has as well as the reaction and medication required, if any. This includes insect bites or stings, foods, nuts, medications, or any other allergy. (Type "N/A" if this doesn't apply to your child)

In the text box below, please list: medication, symptom/condition, dosage, date started, and current side effects. (Type "N/A" if this doesn't apply to your child)

Please list any medical condition that your child has

Please provide your insurance carrier and the policy/group number.

By completing this registration online and entering your name below, you hereby agree to the following: Should an emergency arise, it is understood that a conscientious effort will be made to locate the undersigned parent(s)/guardian(s) before any action will be taken. Should none of the above named individuals be available to give consent, I/we hereby authorize a responsible adult agent of the school to give consent to whatever immediate treatment is deemed necessary or advisable. I/we hereby assume financial responsibility for all medical treatment, hospitalization, and other costs arising out of any emergency. I/we give permission to my/our child’s participation in any excursions with his/her class/camp which occur during his/her visit as a visiting student of the Enchanted Play Garden (EPG) and I/we realize there are risks inherent in my/our child’s participation in such activities and I/we assume all risks. Accordingly, I/we intending to be legally bound, hereby release the EPG from any and all claims, damages, or other liabilities based on negligence of the school or its employees or other agents. Photo Permission/Release: I hereby authorize EPG, or parties designated by EPG, to take photos or other images, written or spoken statements (including quotations from conversations and correspondence), and/or video or other recordings, of or including our/my child and ourselves/myself, without compensation, and use these materials, including reproduction or display on the worldwide web (i.e. websites, Facebook, Instagram, You Tube) and in catalogs or other materials, or for any other promotional or educational use. We/I understand our right to opt out of any component of this provision through the submission of a separate written and signed request to the Office. EPG Summer Camps will follow all covid-related health measures that are in place at the time of the camps. In case of a necessary cancellation of the summer camps, we will reimburse families for any unused portion of a camp week according to our cancelation policy. EPG is not liable for any additional loss or costs incurred by parents.

Parent Signature (1)

Parent Signature (2)