Summer Care Enrollment Form

Summer Care Enrollment Form
General Information
Child's Name *

First Name Last Name
Child's gender *

male female
Child's birthdate *

Month Day Year
Date
Grade child just finished *
Child's weight **used for emergency personnel, if needed** *
Mother's Name

First Name Last Name
Father's Name

First Name Last Name
If parents are separated or divorced, with whom does the child live?
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
mother's phone

Area Code Phone Number
mother's email
example@example.com
father's phone

Area Code Phone Number
father's email
example@example.com
what is the preferred communication choice?

phone call text email
emergency contact #1

First Name Last Name
Phone Number

Area Code Phone Number
relation to child
emergency contact #2

First Name Last Name
Phone Number

Area Code Phone Number
relation to child
Type a question
The following are authorized by me topick up my child from TCA summer care.

* each authorized person must present valid photo ID*

If more than two authorized pick ups are needed, please call the office and let us know.
Authorized pick up #1

First Name Last Name
Authorized pick up #2

First Name Last Name
Medical Information
Is your child on any medication? *

yes no
If yes, what medicine?
Dosage amount?
Is the Medicine to be administered during summer care hours?
Does your child have any allergies? *

yes no
If yes, what allergies?
Can TCA administer medicine (if necessary) such as Tylenol, Benedryl, Tums, etc?

Yes No Yes, but call me first to notify
In the event of illness or injury to my child which requires emergencry medical treatment, TCA will contact the following doctor if the parents cannot be reached.
Doctor

First Name Last Name
Doctor's office address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Doctor's office phone

Area Code Phone Number
Emergency Room of my choice: *
I hereby release the TCA Summer Camp Program from any claim arising out of the doctor's actions. *

Clear
Acknowledgement
I give my permission for my child to take part in all TCA Summer Camp activities, including sports and camp sponsored
trips away from the school property provided that I am informed in advance. I absolve TCA Summer Camp from
all liability to me or my child because injury to my child at TCA Summer Camp or during any TCA Summer Camp activity.
I understand that discipline will be used to maintain control of camp activities. Discipline options include, but are not
limited to: time out, quite time, removal from the specific activity, game, field trip for the day/week/entire program;
removal from the TCA Summer Camp program for the day/week/entire program.
I agree to be responsible for all financial obligations of my child attending TCA Summer Camp.
1. I understand that the registration fees are non-refundable
2. I understand that weekly payments are due each Monday.
3. I understand that my child’s account cannot be more than a week behind.
4. I understand that if my child does not return to TCA Summer Camp, I owe any money on my child’s account.
Signature *

Clear
Today's Date *

Month Day Year
Date
How did you hear about our summer program? *

My child attended last year A friend referred me A family member referred me My child attends TCA I attend Temple Baptist Church Online Ad
Should be Empty:

Summer Care Enrollment Form

General Information

Medical Information

Acknowledgement