Enrollment Form

Enrollment Form

Use this form to enroll your child for Octavian Summer Babysitting. Submit another form for another child's enrollment.
Grown-up's Details:
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Please verify that you are human

Child Details:
Child name

First NameLast Name
Age
Does this child have any medical conditions, allergies, or medication?
If so, please list all of them.
Is this child allowed to commute to and from the program alone?
Is there another grown-up (besides yourself) that will pick-up/Drop-off this child?
Add another Child?

Child Name

First NameLast Name
Age
Does this child have any medical condition, allergies, or medication?
If so, Please list all of them.
Is this child allowed to commute to and from the program alone?
Is there another grown-up (besides yourself) that will pick-up/drop-off this child?
Add another child?

Child Name

First NameLast Name
Age
Does this child have any medical conditions, allergies, or medication?
If so, please list all of them.
Is this child allowed to commute to and from the program alone?
Is there another grown-up (besides yourself) that will pick-up/drop-off this child?
Add another Child?

Child Name

First NameLast Name
Age
Does this child have any medical conditions, allergies, or medication?
If so, please list all of them.
Is this child allowed to commute to and from the program alone?
Is there another grown-up (besides yourself) that will pick-up/drop-off this child?

Emergency contact information:
Emergency Contact #1:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Who is this person to your child?
Is this person allowed to Pick-Up/Drop-off your child?
Emergency contact #2

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Who is this person to your child?
Is this person allowed to Pick-Up/Drop-off your child?

Policy Acknowledgment:

Please read thoroughly and provide your signature in the designated areas below.
I, Your Name* ,understand the mission and goal of Octavian Summer Babysitting is to inspire meaningful connections between people, nature, and creativity. Through this program my child will be provided the opportunity to develop by learning to take risks judge their limits and practice responsibility both in the camps indoor and outdoor space. Every reasonable precaution will be taken by the staff to prevent serious accidents and injuries. However I understand the implied risk of exploring outdoors and I will not hold Octavian Summer Babysitting, babysitters or other parents/caregivers liable for accidents. In participating in this program I, the parent or legal guardian, recognize that the activities at the house may involve physical and outdoor activity and grant permission for my child to participate in all activities of the program and to walk parks and other outdoor spaces within the neighborhood as well as ride public transportation [limited use]. In consideration of allowing my child to participate in its activities I assume all risks and hazards incidental to such participation including the risk of serious injury to the child and do hereby waive on the child’s behalf and on behalf of myself and other relatives of the child any and all claims relating to such participation against Octavian Summer Babysitting, its employees, organizers, and other participants. Octavian Summer Babysitting or its representative has my permission in an emergency where I cannot be located immediately to transport my child at my expense to the emergency room of the nearest hospital. The hospital and its staff have my permission to provide treatment that is deemed necessary for the wellbeing of my child.
Signature

Services
prevnext( X )
Child(ren)
Please select how many children you would like to enroll.

Free Quantity



Day (Mon - Thu)
This means you are paying for 1 day(9:00 AM - 3:00 PM), you may have more than 1 in quantity. You will choose your date(s) in the next section.

$20.00 Day amount
Item subtotal:$0.00



4 Day week
This means you are paying for a 4-day week (Mon - Thu). You may have more than one in quantity, you will choose your week(s) in the next section.

$80.00 Week amount
Item subtotal:$0.00



5-day week
This means you are paying for a 5 day week (Mon - Fri). You may have more than one in quantity. You will choose your week(s) in the next section.

$110.00 Week Amount



Friday Care
This means you are paying for 1 Friday care slot(9:00 AM - 3:00 PM). You may have more than one in quantity. You will choose your date(s) in the next section.

$30.00 Day amount
Item subtotal:$0.00



After-Care
This means you are paying for 1 aftercare slot (3:00 PM - 6:00 PM) You may have more than one in quantity. Available Mon-Fri. You will choose your date(s) in the next section.

$10.00 Aftercare Day amount



Total

$0.00
Dates
If needed, Input each specific date you would like your child enrolled for.
Rate this form?
Should be Empty:

Enrollment Form

Child Details:

Emergency contact information:

Policy Acknowledgment:

Services*

Services