Summer Camp Registration

Session 1 July 11-14 Session 2 July 18-21

Ages 18 months - 5 years by September 1, 2022

9 a.m. - 1 p.m. *Lunch not provided

18-30 months $175/week 2.5-5 years $150/week

You will be invoiced upon receipt of registration form. Payment is due upon receipt. If needed, a full refund will be offered until April 30, 2022, and a partial refund of half will be offered until May 31, 2022. No refunds will be offered after May 31, 2022.

Student Name

First Name Middle Name Last Name

Birth Date

Month Day Year

Gender

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent/Guardian

First Name Last Name

Parent/Guardian Email

example@example.com

Parent/Guardian Mobile Number

Parent/Guardian Work Number

Summer Sessions

AUTHORIZED PICK UP

I hereby authorize First Presbyterian Preschool to allow my child to leave the preschool with the following persons (other than parent/guardian):

Parent/Guardian Signature

Clear

Emergency Contact (If unable to reach Parent/Guardian)

Allergies/Health Conditions/Dietary Restrictions

Please list any health conditions that your child may have, such as allergies, exsisting conditions, existing illness, previous illness, and/or injuries during the past 12 months, any medication prescribed for long-term continuous use, and any other health information of which the staff should be aware in the space below. If none please write "none".

Authorization for Emergency Medical Attention:

In the event I cannot be reached to make arrangements for medical treatment I authorize any representative of First Presbyterian Preschool of Grapevine to administer first aide and/or to call 911 to transport my child to Baylor Medical Center at Grapevine 1650 West College Grapevine, Texas 76051, 817-488-7546. I authorize and give my consent for any necessary medical treatment, emergency or otherwise furnished by a licensed physician, hospital or emergency treatment clinic. My healthcare provider and I agree to pay for all medical fees incurred in connection with the treatment of my child under the authority granted within. I hereby release First Presbyterian Preschool of Grapevine and any healthcare provider and any other respective agents, employees, officers or representatives from any and all liability for action of my child pursuant to the terms of this

Parent/Guardian Signature

Clear

Photo Release - I hereby give consent for my child's photo to be placed on the First Presbyterian Preschool of Grapevine's Facebook page, website, and in the preschool newsletters.

Water Activities - I hereby give consent for my child to participate in supervised water activities.

Signature

Clear