SUMMER RECREATION REGISTRATION FORM

CAMP #CAMP                 FEE


(Numbers precede camp name and week)
                    Please check off which camp your child is going to or enter the times for the 4, 5 or 9 hour camps.

 

  7:15-6:00 PM 9 HOUR CAMP 5  HOUR CAMP 4 HOUR CAMP



Name Grade or Age Home Phone

 

AddressTownState/Zip

 

Parent/Guardian Name  

Emergency Cell or Work #

 

                                          Please select payment method CashCheckMC/VISA

                                                              Make check or money orders payable to SBCS

Credit Card #Exp. Date

Signature

                                               Registrations will not be acknowledged unless camp is cancelled.

Tuition Refund Policy– No refunds or credits will be issued once camp has begun.  Withdrawals must be made in writing 5 days or more before camp begins.            A $15.00 cancellation fee will be charged.

 

FOR OFFICE USE ONLY|
Date receivedComputer Entry #Check #CashCredit


 

MEDICAL RELEASE FORM

CHILD'S NAME

In the event that I am unavailable for the purposes of providing parental consent, I hereby authorize the physician(s) and staff at the local hospital to provide such hospital care that includes routine diagnostic procedures and medical treatment as necessary to my minor son/daughter.  I understand that the consent and authorization herein granted do not include major surgical procedures and are valid only during camp.

Physical conditions that the instructor/physician should be aware of (allergies, recurring illness, disabilities, chronic illness, etc.):

Allergies:

 Illness

Disabilities

Date of most recent tetanus immunization:(If more than ten years ago, a booster shot is recommended.) 

I understand that you will try to contact me in the event an emergency occurs and my child needs treatment. 

If  I am not available, Contact 

Phone #Relationship to child

 My family physician is: 

Phone #

The parent or guardian is required to have medical coverage/hospitalization for your child(ren).   Proof of such coverage is required before
child is permitted to attend any Summer Camp (for example, Blue Cross/Blue Shield/Bollinger, Medicaid, etc.)

Please provide the necessary information:

Insurance Company

Type of  Coverage

Policy No.

Name of Policyholder

 PARENT OR GUARDIAN’S SIGNATURE

                       
DATE

In the event of illness or injury requiring treatment or hospitalization, family medical insurance must be used.