Summer Camp Detailed Registration Form

Summer Camp Registration
Camper Information
Camper's Name*

First NameLast Name
Birth Date*

MonthDayYear
Age*
Gender*

MaleFemaleNon-binary
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which weeks of camp are you applying for?

June 16- June 20June 23- June 27June 30- July 3July 7- July 11July 14- July 18July 21- July 25July 28- August 1August 4- August 8August 11- August 15August 18- August 22
Parent/Guardian Information 1
Name*

First NameLast Name
Home Number
Cell Number*
E-mail*
example@example.com
Parent/Guardian Information 2
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Emergency Information

Please list two (2) contacts not already listed on this form, to be used if the parents/guardians cannot be reached.
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
Physician Information
Name*

First NameLast Name
Office Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Is the camper prescribed any medications? If yes, please explain. If camper will need to take medicine during camp time a release will need to be filled out by the doctor. All campers taking medicine must be able to take it independently.*
Authorized Pick-Up Form

The following individuals are 18 years old or older and are allowed to pick up my child from the Poinciana Montessori Camp Program. Those authorized to pick up your child will be asked for photo ID for verification.
Name*

First NameLast Name
Relationship*
Phone Number*
Name*

First NameLast Name
Relationship*
Phone Number*
Name

First NameLast Name
Relationship
Phone Number
Name

First NameLast Name
Relationship
Phone Number
Name

First NameLast Name
Relationship
Phone Number
I understand that no one else will be allowed to pick up my child unless I notify Poinciana Montessori in advance and in writing. This person will also be asked for their photo ID for verification.
Arrival & Sign-in Procedures

I understand that my child must be escorted into the building and a parent/guardian must sign the child in at arrival
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date*

MonthDayYear
Date
Signature*

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Agreement

I, the undersigned, give permission for my child to participate in Summer Camp. I am aware that a completed medical form signed by a physician is required before my child may begin Summer Camp. Also, I understand that enrollment is based on availability. In addition, I am fully aware that to reserve a space, I must make a NONREFUNDABLE deposit of $100.00 per session and submit a completed registration form. I am fully aware that should my child change/add camp sessions after the start of the summer season there is a $25 change fee. I fully understand and approve of my child being photographed for Poinciana Montessori publicity. Lastly, I fully understand that my child is responsible for their possessions. I have read, signed, and agreed to the registration requirements.
Date*

MonthDayYear
Date
Signature*

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Permission Form

I hereby grant permission for my child to use all equipment and participate in all activities of Poinciana Montessori.

I hereby grant permission for my child to leave the premises of Poinciana Montessori, under proper supervision of Poinciana Montessori staff, for neighborhood walks, park activities and field trips. It is my understanding that these trips will be taken
over the camp session without further consent from me.
Date*

MonthDayYear
Date
Signature*

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Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Poinciana Montessori during the selected camp. In exchange for the acceptance of said child’s candidacy by Poinciana Montessori, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Poinciana Montessori and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Poinciana Montessori including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Poinciana Montessori and its affiliates including Directors, Counselors and Teachers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered camp season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

MonthDayYear
Date
Signature

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Summer Camp Registration

Camper Information

Parent/Guardian Information 2