Summer Camp Registration Form
These forms are required for your children to attend camp.
REGISTRATION CLOSED
Camper's Information
Camper Name
*
Age
*
Date of Birth
*
mm/dd/yyyy
NOTE -
Children need to have completed Kindergarten before they are eligible to participate in traditional day camp.
Entering Grade in 2022/23
*
Please Select
1st
2nd
3rd
4th
5th
6th
7th
8th
School Camper Attends
*
T-Shirt Size
*
Please Select
SMALL
MEDIUM
LARGE
X-LARGE
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Parents' Information
Parent/Guardian 1
Parent/Guardian 1
*
First Name
Last Name
Relationship to Child
*
E-mail
*
Cell Phone
*
Home Phone
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Work Name
*
Or enter N/A if not applicable
Parent's Work Phone
*
Parent's Work Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where would you like to be reached while your child is at camp?
*
Cell Phone
Work Phone
Home Phone
Parents' Information
Parent/Guardian 2
Parent/Guardian 2
First Name
Last Name
Relationship to Child
E-mail
Cell Phone
Home Phone
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Work Name
Or enter N/A if not applicable
Parent's Work Phone
Parent's Work Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where would parent/guardian 2 like to be reached while your child is at camp?
Cell Phone
Work Phone
Home Phone
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Emergency Contacts/Authorized Pickup
Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.
Emergency Contact #1
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Relationship to Child
*
Authorized Pick Up?
*
Yes
No
Emergency Contact #2
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
Relationship to Child
Authorized Pick Up?
Yes
No
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Medical / Health Information
Name of Physician or Clinic/Hospital
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Is the Camper up-to-date on all immunizations?
*
Yes
No
Attach immunization record or waiver/ Email to Camp/ or Bring in person
Does your child have any food, medication or environmental allergies?
*
Yes
No
Allergies? Check all that apply
*
Food
Medication
Environmental
Please list and explain any allergies
*
0/150
Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child?
*
Yes
No
Does your child have a special health or medical condition?
*
Yes
No
Please explain
*
0/150
Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during child care hours?
*
Yes
No
Is your child currently using any medication, food supplement or medical food (such as electrolyte solution)?
*
Yes
No
Please explain
*
0/150
If yes, does this medication, food supplement, or medical food need to be administered at the day camp?
*
Yes
No
Name of medication
*
Exact dosage
*
To be administered at the following times
*
For the following period of time
*
If your child's medication meets any of these criteria: A physician's instruction is needed for a nonprescription medication (e.g. child is underage or underweight per the label instructions); or It is a sample medication without a prescription label; or The nonprescription medication is to be given longer than three consecutive days within a fourteen day period or is a topical product or lotion that is being used for a skin ailment and is to be given no longer than fourteen consecutive days; or The child is on a modified diet (an entire food group is eliminated); or The medication contains codeine or aspirin. ***The topical product or lotion and the physician's instructions exceed the manufacturer's instructions or use
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?
*
Yes
No
Please explain
*
0/150
Does this dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group?
*
Yes
No
List any history of hospitalization, outpatient surgery, or previous health concerns that would be needed to assist the staff or medical personnel in an emergency situation.
*
0/200
List any additional information about your child that would be useful for staff to know, such as fears, eating or sleeping habits, or special routines. This information should not be medical or health related, as that information should be included in the previous questions.
*
0/200
My Architecture Workshops Inc. and Summer Camp has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.
*
Type first and last name above to consent
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Payment and Statement of Understanding
My Products
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Six Week Session (K-2 Grades)
$
750.00
Six Week Session (3-5 Grades)
$
750.00
Six Week Session (6-8 Grades)
$
750.00
Extended Care
$
100.00
Enter coupon
Apply
Total
$
0.00
Acknowledgement of Policies and Procedures, I have reviewed and received a copy of the center's policies and procedures/handbook located on website: https://www.myarchitectureworkshops.com. The parent/guardian must sign and date all additional waiver forms and return to camp via email: myarchitectureworkshops@gmail.com
*
Yes
No
Sign Document
*
Date Signed
*
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Month
/
Day
Year
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Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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