Summer Camp Registration

Campers must enroll for the entire duration of a session.

Parent/Guardian Information 1

Parent/Guardian Information 2

Emergency Information

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

Physician Information

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.

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.

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 $50.00 per week, complete payment for each week of camp by May 30th and submit a completed registration form.  Lastly, I fully understand that my child is responsible for their possessions. I have read, signed, and agreed to the registration requirements.

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.

Media Release Form

I grant permission to Poinciana Montessori, its agents, and its employees the irrevocable and unrestricted right to produce photographs and video taken of my child, myself, and members of my family while at Poinciana Montessori for any lawful purpose including publication, promotion, illustration, advertising, trade, or historical archive in any manner or in any medium by Poinciana Montessori. I hereby release Poinciana Montessori and its legal representatives from liability for any violation or claims relating to said images or video.

Furthermore, I grant permission to use the statements of my child, myself, or my family members given during an interview or evaluation with or without my name for the purpose of advertising and publicity without restriction to time limit or geographic area. I waive my right, my child’s rights, and my family’s rights to any and all compensation stemming from the use of these materials.

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.