MPAC ENROLLMENT FORM

Making Powerful Adaptive Change
MPAC
ENROLLMENT FORM
Childs Name*
DOB*
Grade*
FemaleMale
Mothers Name*
Address*

Address

Street Address Line 2

CityState / Province

Zip Code
Home Phone*
Format: (000) 000-0000.
Place of Employment
Work Hours
Work Phone
Format: (000) 000-0000.
Employment Address
Cell Phone*
Format: (000) 000-0000.
Email*
example@example.com
Fathers Name
Home Phone
Format: (000) 000-0000.
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Place of Employment
Work Hours
Work Phone
Format: (000) 000-0000.
Employment Address
Cell Phone
Format: (000) 000-0000.
Email
example@example.com
Guardians Name
Home Phone
Format: (000) 000-0000.
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Place of Employment
Work Hours
Work Phone
Format: (000) 000-0000.
Employment Address
Email
Format: (000) 000-0000.
Email
example@example.com
T-SHIRT ORDER FORM: (Circle the correct size)
Child SmallChild MediumChild LargeChild X-LargeAdult SmallAdult MediumAdult LargeAdult X-Large
Making Powerful Adaptive Change
1. Emergency Contact Name*
Phone number*
Format: (000) 000-0000.
Address
City
Zip Code
Relationship to child
SECOND
2. Emergency Contact Name*
Phone Number*
Format: (000) 000-0000.
Address
City
Zip Code
Relationship to Child*
PERSONS AUTHORIZED TO PICK UP YOUR CHILD
(OTHER THAN PARENTS)
Name
Phone Number
Format: (000) 000-0000.
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Relationship to child
Name
Phone Number
Format: (000) 000-0000.
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Child
Name
Phone Number
Format: (000) 000-0000.
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Child
Are there any persons who are NOT permitted to pick up your child?
1
Relationship to Child
2
Relationship to Child
Doctors Name*
Doctor's Phone Number*
Format: (000) 000-0000.
Dentists Name*
Dentist's Phone Number*
Format: (000) 000-0000.
1st Choice of Hospital*
Phone Number
Format: (000) 000-0000.
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Health Insurance Information*
Policy Number*
Group Number
If Physician cannot be reached, what action should be taken
other explain
Any Medical Problems
Any Known Allergies
Any recent injuries or hospitalizations
Current Medication
Any additional information
Authorization to take pictures: The parent of the above registered child gives authorization allowing the child to be photographed, and the photos to be used in the promotion of the MPAC.
Parent Signature*

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Date*

MonthDayYear
Date
Transportation Authorization: The parent of the above registered child gives authorization allowing the child to be transported to and from home. Furthermore, the parent gives authorization to transport the child on MPAC scheduled field trips.
Parent Signature*

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Date*

MonthDayYear
Date
Have received a copy of the Parent Handbook including discipline policies and I understand that these policies apply to all child care programs at the MPAC.
Parents Signature*

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Date*

MonthDayYear
Date
I hereby give my permission to the BFE MPAC camp staff to seek medical treatment (private physician or hospital) or transportation for my child should any emergency arise. I understand that a
Medical Insurance Co Name*
Policyholder name*
Address*
Birthdate*

MonthDayYear
Date
Policy Number*
Relationship to child*
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conscientious effort will be made to locate me or my spouse before any action will be taken.
Parents Signature*

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Date*

MonthDayYear
Date
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I/We have been personally advised of, and received a copy of the personal rights contained in the Ohio Revised Code Regulations at the time of admission. (Included in Parent Handbook)
POLICIES AND AGREEMENT CONTRACT
Parents Signature*

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Date*

MonthDayYear
Date
I understand that whenever I drop off or pick up my child I must enter the Day Camp site to sign the roll sheet and write down the time I dropped my child off or the time I picked my child up I understand that the person picking up my child including parents may have to provide a photo ID if not recognized by staff*

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Initial Here blanks*
Initial Here blanks*
A late fee of $15.00 per 15 minutes will be collected for any child picked up after 3:30 p.m. Parents who chronically leave their children after the 3:30 p.m. closing hour will be terminated from this program. Any child who has not been picked up by 4:30 p.m. will be turned over to local authorities if an emergency contact cannot be located. The BFE MPAC camp is not responsible for a child's lost or broken articles. Please remember to label your child's belongings. Children are not allowed to bring possessions from home i.e. toys, Game Boys, action figures, etc*

I understand that I will be required to pay for all sessions that I check unless I give a two weeks written notice. Failure to comply will result in cancellation of all future sessions. I understand that whenever I drop off or pick up my child, I must enter the Day Camp site to sign the roll sheet and write down the time I dropped my child off or the time I picked my child up. I understand that the person picking up my child, including parents, may have to provide a photo ID if not recognized by staff. Tuition payment may be made by credit card or cash. Cash payments must be made at the BFE Office 526 S. Main Street #705 Akron, Ohio 44311. Payment will be due on Tuesday prior to the week of attendance.
Initial Hereblanks*
I understand by signing this form, I agree to abide by these policies and all policies contained in the Summer Day Camp Handbook.
Parent Signature*

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Date*

MonthDayYear
Date
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BFE MPAC Summer Camp Media Waiver

I (parent/guardian's name) acknowledge that during the camp, my child will be educational supplies, I release BF Empowerment Center MPAC camp program from all liability for injuries sustained while my child attends MPAC summer camp. I, do hereby release to BFE, its assigns, licensee, affiliates, and legal representatives to use my/my camper picture, images of art, portrait, photograph, or video image in all forms and media and all manners including composite or distorted representations, for any and all purposes including advertising in all forms, for unlimited time, and I waive the right to inspect or approve the finished product, including written copy, that may be created in connection therewithin. I have read this release and am fully familiar with its contents.

Iam the parent and/or guardian of the minor named above and have the legal authority to execute the above release. I approve the foregoing and waive any rights in the premises.

I give my permission for the BFE MPAC Camp to use without limitation or obligation, photographs, film footage, or tape recordings which may include my or my children's image or voice for the purpose of promotion or interpreting BFE MPAC programs.
Parent/Guardian Name*
Child's Name*
Parent/Guardian Name*
Parent's Signature*

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Date*

MonthDayYear
Date
Signature*

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Signature*

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Should be Empty:

MPAC

ENROLLMENT FORM

SECOND

PERSONS AUTHORIZED TO PICK UP YOUR CHILD

(OTHER THAN PARENTS)