CHILDREN INFORMATION

Child(ren) name: name of child(ren)*
Preferred Name: nicknames .
Date of birth:   dob*   
Gender:   gender   
Grades :   school grade  
School attending:   school   
Address:   address*   

FATHER'S INFORMATION
Father's Name:Father's name* .
Cell phone: cell phone* .
Home Phone:   home phone .
Work Phone:   work phone    

MOTHER'S INFORMATION
Mother's Name:Mother's name* .
Cell phone: cell phone* .
Home Phone:   home phone .
Work Phone:   workphone    

AUTHORIZED PICKUP PERSONS (ID REQUIRED)

Person #1 name* relationship*   phone*   
Person #2 name    relationship      phone   

EMERGENCY CONTACT (OTHER THAN PARENTS)

Person #1 name* relationship*   phone*   
Person #2 name    relationship      phone   

MEDICAL NEEDS AGREEMENT
Please enter Medical Alert Information (allergies, medical and/or handicapping conditions):
allergies/ medical condition   
Preferred Physician: doctors name* Address:   dr address*   . Phone :     dr phone*   . Preferred Hospital:   name of hospital*   

PARENT AUTHORIZATION
I hereby give permission for my child, {input97:shorttext-1} , to attend event indicated above. I further certify that this health history is correct as far as I know and the person herein described has permission to engage in all prescribed activities, except as noted. I also hereby give permission for the staff to inspect the content of any or all of my child’s personal belongings, and to withhold and/or dispose of any improper or illegal contents. Permission is given to Tampa Community Center to use photographs (individual or group) and/or multimedia images and recordings in the best interest of Tampa Community Center. As parent or legal guardian of {input97:shorttext-1} . I certify that all the information on this form is complete and accurate.

Please sign*      NAME*   

PAYMENT POLICIES
Payment Structure: Camp timing: Full day: 9am – 4pm Half day: 9am - 12pm or 1pm - 4pm *Before-care $20 per day per child and after-care $20 per day per child. One time NON REFUNDABLE registration fee $25. Payment Policies:
Payment options: Cash, Credit Cards, Debit Cards, Money Orders and Cashier’s Check only. No Personal Checks accepted. Please make payments payable Tampa Community Center. Billing Deadline/Due Date: Payment has to be made latest by the Friday prior to the start of the camp week. Payments are due in full by close of business hours on the billing deadline of each camp week. Online registration requires payment in full by credit card only. Registration will be cancelled if the balance is not paid prior to the billing deadline of each camp week. Late payment fee of $25.00 will apply if balance is not paid after the billing deadline and 10% each day thereafter. If your child does not attend on the day payment is due, then you should make your payment on the business day prior to the billing deadline to avoid late fees.
Refund and Cancellation Policies: No refunds will be given if cancelled less than 7 days prior to billing deadline for the camp session. Changes and cancellations must be made in writing 7 days before the billing deadline for the session to receive a refund (less non-refundable registration fee). Payments will not be refunded for changes and cancellations made after the billing deadline. All refunds are subject to a $50.00 processing fee.
Additional Fees: A $20 change fee will be applied to all changes made prior to the billing deadline. Children placed in Tampa Community Center Kids Summer Camp Extended Care without advance notice will accrue a drop-in rate of $20.00 per child for each 15 minute increment after 4pm on each camp day which will be automatically billed to the account on file.
Late and Illness Pick-up: A late pick up fee of $20.00 per child for each 15 minute increment after 4pm on each camp day. All efforts will be made to contact the parent and/or responsible persons as listed on the emergency contact sheet. If the child has not been picked up by 45 minutes past closing, the Police and or the family crisis center will be called to pick up the child. In case of illness the child must be picked up within the hour. All families must have back-up care if a child needs to be excluded from group-care. Camp fee reimbursement (whether full or partial) is not given for days missed due to illness.
Contract Changes: The parent/guardian is responsible for informing the center in writing of any contract changes. Changes in address, telephone numbers, and/or health must be submitted immediately.
Tampa Community Center Membership: Child does not need to be a member to attend Tampa Community Center Kids Summer Camp programs. I understand that children who are Tampa Community Center Members will receive a discounted rate.
By signing up for camps, I understand and accept the above policies and agree that I am responsible for payment. I have read the information above and understand the policies and options provided for me to pay for summer camp. I take full responsibility for the completion of this payment agreement and will make payments accordingly without notice or reminder. I understand that if not paid in full by the billing deadline of each camp session, I will incur a $25 late fee, and 10% each day thereafter.I also acknowledge that I am responsible for possible additional charges and/or fees as stated in the terms of this financial agreement that are not covered under my weekly contracted amounts
 
Signature*   NAME*     RELATIONSHIP*

CONSENT & RELEASE FORM
Health Insurance & Immunization Records
It is the responsibility of every individual participant or his/her parent(s) or legal guardian to provide his/her own accident and health/dental coverage while participating in all Tampa Community Center activities. The Tampa Community Center does not provide any accident or health/dental coverage for its members or guests. The parent(s) or legal guardian are responsible for providing the Tampa Community Center with every individual participant’s up-to-date immunization record and proof of health insurance.
Minors
The Tampa Community Center cannot accept responsibility for minors (children under 18) except when they are under the supervision of an appropriate employee. Parents/guardians will be responsible for notifying staff of a child’s absence, late arrival, early or late pick-up and any special circumstance. For the protection of participants under the age of 18, the Tampa Community Center has adopted a sign-in/out policy for all programs held by the Tampa Community Center. Minor children must be picked up by an adult after camp.
Consent & Release
As the parent, agency/representative, or legal guardian, I hereby give consent for the Tampa Community Center to provide all emergency medical/dental care prescribed by a duly licensed physician or dentist for my child/relative under whatever conditions are necessary to preserve the life, limb or well-being. I acknowledge and agree that this general release of liability of the Tampa Community Center is binding upon me personally as well as in my capacity of the parent or guardian of my child and on my heirs, personal representatives, successors and assigns. In consideration of participation in this program, I hereby indemnify, hold harmless and release the Tampa Community Center, its agents, its employees and its volunteers from any and all liability for injury suffered by myself or my child arising from or connected with this program. I assume all risk for any injuries.

By signing up for camps I acknowledge that I have read and agree to the special considerations noted above.
Signature*   name*     relationship*   

LIABILITY RELEASE FORM/RELEASE OF ALL CLAIMS FOR TAMPA COMMUNITY CENTER

We / I, being of 18 years of age or older, do for ourselves/myself and for an on behalf of our/my child, {input97:shorttext-1}, hereinafter referred to as “child-participant”, hereby release, forever discharge and agree to hold harmless Tampa Community Center and the directors/managers/members/officers , employees and agents , thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, or any nature whatsoever (except for gross negligence) which may be incurred by the undersigned and the child-participant that occur while said child is participating in Tampa Community Center activities, summer camps, events, programs, games, worship services, and service ministry events.
Furthermore, we/I, and on behalf of our/my child-participant hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein.
Further, authorization and permission is hereby given to Tampa Community Center to furnish any necessary transportation, food and lodging for this child-participant.
The undersigned further hereby agree(s) to hold harmless and indemnify Tampa Community Center, its directors/managers/members/officers, employees and agents, for any liability sustained by Tampa Community Center as the result of the negligent, willful or intentional acts of said child-participant, including expenses incurred attendant thereto.
We/I are the parent(s) or legal guardian(s) of this child-participant, and hereby grant our/my permission for him/her to participate fully in activities of Tampa Community Center and hereby give our/my permission to take said child-participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills if any (copy of insurance card and vaccination records attached).
Further, should it be necessary for the child-participant to return home from camp /event due to medical reasons, disciplinary actions or otherwise, we/I hereby assume all transportation costs.

Signature*   name*     relationship*