Knox Academy Summer Camp Registration Form
Please complete a new form for each camper.
Child's Name:
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First Name
Last Name
Birthdate:
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Month
-
Day
Year
Date
Gender:
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Rising Grade:
*
School:
*
Desired Name Tag:
What does your child prefer to be called?
Please provide any medical or dietary restrictions your child may have:
*
How did you hear about Camp?:
*
Please Select
Word of Mouth
Facebook
Instagram
Referral
School
Other
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Identifying Information
Mother's/Guardian's Name #1:
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First Name
Last Name
Contact Phone Number:
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Area Code
Phone Number
E-mail Address:
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer or School Name
*
Employer/School Phone Number:
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Area Code
Phone Number
Employer/School Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father/Guardian #2:
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First Name
Last Name
Contact Phone Number:
*
-
Area Code
Phone Number
E-mail Address:
*
Employer or School Name
*
Employer/School Phone Number:
*
-
Area Code
Phone Number
Employer/School Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact and Persons Authorized to Take Child from Facility (other than a parent)
Emergency Contact #1:
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First Name
Last Name
Phone Number:
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-
Area Code
Phone Number
Relationship to child:
*
Emergency Contact #1 Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact #2:
*
First Name
Last Name
Phone Number:
*
-
Area Code
Phone Number
Relationship to child:
*
Emergency Contact #2 Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Development
Please describe the child's development (Personal development, behavior, patterns, habits, and individual needs):
*
Does camper have special behavioral needs or IEP? Please describe.
*
Do you have anything else you'd like us to know?
Authorization for Emergency Medical Care
I UNDERSTAND THAT I WILL BE NOTIFIED AT ONCE IN CASE OF AN EMERGENCY WITH MY CHILD, AND I WILL MAKE ARRANGEMENTS FOR MEDICAL CARE OF MY CHILD WITH THE PHYSICIAN OR HOSPITAL OF MY CHOICE. IF I CANNOT BE REACHED TO MAKE NECESSARY ARRANGEMENT, OR IN A CRITICAL EMERGENCY REQUIRING MEDICAL CARE, I AUTHORIZE KNOX ACADEMY LLC TO CONTACT THE FOLLOWING:
Physician or Clinic Name:
*
Physician or Clinic Phone Number:
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Area Code
Phone Number
Preferred Hospital Name:
*
Preferred Hospital Phone Number:
*
-
Area Code
Phone Number
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Acknowledgements
Please initial next to each.
I have received a copy of Knox Academy LLC's policies pertaining to the admission, care, and discharge of children.
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Parent/Guardian Initials
I have been informed that a copy of the licensing rules for child care centers is available at Knox Academy LLC for review.
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Parent/Guardian Initials
Knox Academy LLC and I have agreed on a plan for continuing communication regarding my child's development, behavior, and individual needs.
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Parent/Guardian Initials
When my child is ill, I understand and agree that s/he may not be accepted for care or remain in care.
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Parent/Guardian Initials
I understand that before the first day of attendance by my child, I will provide proof of age-appropriate immunizations or exemption from immunizations.
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Parent/Guardian Initials
I have been notified that I may request notice at initial enrollment or any time there after whether there are children currently enrolled in or attending the facility for whom an immunication exemption has been filed.
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Parent/Guardian Initials
I understand that no field trips will take place during summer camp and my child will not be transported from Knox Academy LLC.
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Parent/Guardian Initials
I agree to pay a fee of $2 per minute for every minute my child is picked up after 12: p.m. for a morning camp and 4:00 p.m. for an afternoon or full day camp. There is no grace period for late pick up. This fee will be billed and must be paid on the next invoice.
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Parent/Guardian Initials
Knox Academy LLC uses the Wonderschool app for continuing communication regarding my child’s development, behavior, and individual needs. If this changes, I will be notified.
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Parent/Guardian Initials
I give my consent for my child to be photographed during attendance at Knox Academy LLC. This consent releases from liability all personnel of Knox Academy LLC and any others who have received permission to take photos in the Center. This consent also gives permission for photos taken to be used in publications, shown at meetings, and/or settings where the development of children is being studied and in promotions for Knox Academy (i.e., social media, school website).
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Parent/Guardian Initials
I acknowledge that I have received and read a copy of Knox Academy LLC policies pertaining to admission, care, and discharge of children. I was given the opportunity to ask questions and/or voice any concerns.
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Parent/Guardian Initials
Camp Payment
Payment is due at time of registration. You will receive an invoice from Wonderschool once your application has been processed. The processing fee for payments made by May 5, 2025, will be waived. Any payment received after May 5th will include a 2.85% + $0.30 per transaction processing fee. Tuition payments are non-refundable, except in the event that summer camp is canceled by Knox Academy.
Select the Summer Camp Themes your child will attend:
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All Camps Weeks 1 - 8 - Full Day
Week 1 (June 2 - June 6) Morning - Swoop Into Action
Week 1 (June 2 - June 6) Afternoon - Building a Brighter Future
Week 2 (June 9 - June 13) - Morning - A Whole New World
Week 2 (June 9 - June 13) - Afternoon - Under the Sea
Week 3 (June 16 - June 18 / 3 DAY CAMP!) Morning - Camp Castaway
Week 3 (June 16 - June 18 / 3 DAY CAMP!) Afternoon - Camp Cha-Ching!
Week 4 (June 23 - June 27) Morning - Eco Explorers
Week 4 (June 23 - June 27) Afternoon - Makerspace
Week 5 (June 30 - July 3 / 4 DAY CAMP!) Morning - The Great Game Off!
Week 5 (June 30 - July 3 / 4 DAY CAMP!) Afternoon - Listen to Your Art
Week 6 (July 14 - July 18) Morning - Totally Tie Dye
Week 6 (July 14 - July 18) Afternoon - Spy School
Week 7 (July 21 - July 24 / 4 DAY CAMP!) Morning - Time Travelers
Week 7 (July 21 - July 24 / 4 DAY CAMP!) Afternoon - Around the Campfire
Week 8 (July 28 - August 1) Morning - Mini Makers Market
Week 8 (July 28 - August 1) Afternoon - Shoot for the Stars
Waiver
TERMS & CONDITIONS: My family and I hereby waive and release Kimberly Knox, Knox Academy LLC, and their agents from claims for damages and/or injuries incurred while participating in or as a spectator of Knox Academy Summer Camp. We agree that COVID-19 is contagious in nature and the Participant may be exposed to or infected by COVID-19 and such exposure may result in personal injury, illness, permanent disability, or death and voluntarily agree to assume all of the foregoing risks. Please sign your name below.
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