PCWS Summer Camp Registration

PCWS Summer Camp Registration
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Child's Current Grade*
Parent/Guardian's Contact Information
Parent/Guardian 1*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 2

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information

Please list at least one local person to contact in case of emergency.
Primary Emergency Contact (after guardians)*

First NameLast Name
Relationship to Child:*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Emergency Contact (after guardians)

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pick Ups

Please list any people other than parents/guardians to whom your child may be released.
Primary Authorized Pick Up (after guardians)

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Authorized Pick Up (after guardians)

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are there any chronic problems, pertinent developmental information, or any special accommodations that PCWS should be aware of?*
Are there any allergies, intolerances and/or sensitivities to food, environmental or other substances?*
Authorization of Consent
Release and Waiver of Liability Agreement
This Agreement is entered into by and between First Name* Last Name* ("Guardian") on behalf of the minor participant ("Participant") First Name* Last Name* and Potomac Crescent Waldorf School ("PCWS"), as of the date set forth below.

Guardians signing this Agreement give permission for the Participant to take part in any and all activities authorized by PCWS. Guardians further release and agree to indemnify, defend and hold harmless, PCWS and its teachers, employees, independent contractors and agents from any liability, claims, causes of action, damages, costs and expenses (including, without limitation, reasonable attorney's fees and disbursements) for any accident, personal injury, or damages suffered in connection with these activities, on or off school property.

PCWS agrees to notify the Guardian whenever the Participant becomes ill or injured. The Guardian will arrange to have the Participant picked up from school as soon as possible if requested by PCWS.

The Guardian authorizes PCWS to obtain immediate medical care if any emergency occurs when the Guardian cannot be located immediately. If there is an objection to seeking emergency care, the Guardian must state in writing any objections and the reason for the objection.

The Guardian will inform PCWS and the Center for Disease Control within 24 hours or the next business day after the Participant or any member of the immediate household has developed any reportable communicable disease, as defined by the State Board of Health, except for life threatening disease, which must be reported immediately.
Guardian's Signature*
Date*

MonthDayYear
Date
Guardian's Signature
Date

MonthDayYear
Date

June 22-26 (4-6 year olds)

$375.00

June 22-26 Arts & Crafts (Grades 2-6)

$375.00

July 6-10 (4-6 year olds)

$375.00

July 6-10 Historic Alexandria (Grades 2-6)

$375.00

July 13-17 (4-6 year olds)

$375.00

July 20-24 (4-6 year olds)

$375.00

Enter coupon

Total

$0.00

Credit Card

Should be Empty:

PCWS Summer Camp Registration

Parent/Guardian's Contact Information

Emergency Contact Information

Authorized Pick Ups

Authorization of Consent

Release and Waiver of Liability Agreement

Credit Card