Palermo Summer Camp Registration Form

Palermo Summer Camp

Registration Form
Student’s Name
Age
Date of Birth

MonthDayYear
Date
School Currently Attending
Home Phone
Format: (000) 000-0000.
Mother’s Name
Cell. Phone
Format: (000) 000-0000.
Workplace
Work Number
Email Address
example@example.com
Father’s Name
Cell. Phone
Format: (000) 000-0000.
Workplace
Work Number
Email Address
example@example.com
Please list people authorized to pick up child:
1. Name
Relation
Phone #
Format: (000) 000-0000.
2. Name
Relation
Phone #
Format: (000) 000-0000.
3. Name
Relation
Phone #
Format: (000) 000-0000.
Extended Care/ Cuido Extendido
Individualized Tutoring

Other
How many days for tutoring?
Emergency Authorization Consent
I/We the undersigned parents or legal guardians do hereby give authorization/ consent for medical treatment. In the event my child becomes ill or injured during the summer program, PPS is authorized to take one of the following actions: (1) provide first aid; (2) release my child to the person listed below; (3) take my child to the physician or call for emergency care or call the physician indicated; or (4) Take my child to a hospital and/or give consent for emergency care.
Other person to contact in emergency:
Name
Relation
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Cellular Phone
Format: (000) 000-0000.
Doctor
Phone Number
Format: (000) 000-0000.
Office Address
Please indicate any significant health history that requires special attention
Please list allergies
Parent / Legal Guardian Signature
Date

MonthDayYear
Date
Should be Empty:

Palermo Summer Camp

Other person to contact in emergency: