Summer Camp Enrollment Form

Student Name*

First NameLast Name

Email

example@example.com

SEX*

MaleFemale

Birth Date*

MonthDayYear

Home Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Student Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Name of School*

What Grade Will Your Student Be In This Upcoming Fall?*

T-Shirt Size (Each student will receive a t-shirt $20. Additional shirt are $20 each*

Dietary restrictions*

Parent/Guardian 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

Parent/Guardian 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

Child's Living Arrangements*

Both ParentsFatherMotherOther (If you Click other please provide that Information Below)

The Child may be released to the person(s) signing this agreement or to the following: (Please enter person's Name, Address, Phone Number, Relationship to Child, Relationship To Parent / Guardian)

Person #1*

Person #2*

Person #3*

Physician Name*

First NameLast Name

Phone Number*

Format: (000) 000-0000.

My Child Has The Following Special Need*

Medical Concerns*

Behavioral Concerns: Are there any behavioral needs, challenges, or concerns we should be aware of to help support your child during camp? (If Yes, please briefly explain.)*

No behavioral concernsYes (please explain below)

Behavioral Concerns To Be Aware Of*

Answer The Question Above.*

Answer The Question Above*

Please Read Below And Answer Question *

1) HOURS OF OPERATION Mondays - Thursday 9:00am to 5:00pm. We will be closed in observance of all holidays. 2) LATE ARRIVAL/PICKUP POLICY Please advise staff immediately if you will be arriving later than the pre-arranged time to pick- up your child. If you are not able to pick up your child by 5:00pm alternate arrangements must be made. Please notify staff if an unauthorized person will be picking up your child. Verbal or written permission must be received before we release a child to anyone who is not authorized on the registration form. If a parent cannot be contacted, it is the policy of Newton County Sheriff to call an emergency contact should a child remain in our care after 5:00pm. A late fee of $10.00 for the first minute and $5.00 per minute thereafter per child will apply if a child remains in care after 5:00pm. This late fee is due and payable upon pickup or prior to the next day of classes. 3) TERMINATION OF STUDENT(S) NCSO reserves the right to suspend or terminate care of any child without notice, should it be deemed necessary for the overall safety and well-being of its staff and/or other children in its care. 4) DAMAGES/INJURIES Any damage to personal belongings or injuries to the staff or other children that is willfully caused by your child will be replaced, repaired, or compensated at the cost of the parents. Newton County Sheriff will repair or replace broken equipment due to normal wear and tear. However, should your child purposely damage or break equipment, then the item will be repaired or replaced at the cost of the parents. 5) DISCLAIMER Newton County Sheriff failure to enforce any terms of this agreement shall be construed as a waiver of those terms. Please enter your name below to acknowledge the above.

Please Read Below And Agree to terms By Entering Your Full Name

I understand that Newton County Sheriff will not be responsible to dispense any type of medication to my child. All information including the date, child’s name, name of medication, prescription number and date and time of dosage must be completed. Medicine must be in the original container with my child’s name on it. All medications will kept in the Administrative Office, for my child to administer themselves. I understand that only those persons authorized to pick up my child will be allowed to do so, and that identification may be required at the time of pickup. I understand that if my child is sent home sick, he/she will not be allowed to return to the program until all symptoms have been gone for 24 hours. I understand that it is my responsibility to keep my child’s record current to reflect any significant changes such as telephone numbers, work location, emergency contacts, child’s physician, health status, immunization records, etc. I understand that Newton County Sheriff will keep me informed of any incidents including illnesses, injuries, adverse reactions to medications, etc. which pertain to my child. I hereby grant permission for emergency medical care to be given to my child as deemed necessary by qualified personnel. I understand that payment of all expenses incurred will be the parent/guardian’s responsibility. I understand that Newton County Sheriff will obtain written authorization from me before my child participates in routine transportation field trips, special activities away from the center or water related activities. Additionally, all scheduled trips and activities are the responsibility of the student parents. I hereby release, indemnify, and hold harmless the Newton County Sheriff and its staff from any and all loss or damage to clothing or other personal articles brought to the center and from any and all claims, damages or liabilities for injuries or damage by my child which are not a result of gross negligence by the center or its staff. I hereby warrant that I am entitled to legal custody and possession of my child and am authorized to place my child in the care and custody of the center and am further authorized to sign this agreement. I understand the behavior policy and will share the policy guidelines with my child. I have read and understand all contained in these policies and agree to abide by each and all. Please enter your name below to acknowledge the above.

Student Acknowledgment of Behavior Plan. Please enter your name below to acknowledge the above.*

Parent Acknowledgment of Behavior Plan. Please enter your name below to acknowledge the above.*

We would like to photograph your child for our Newton County Sheriff Websites, While they are involved with their summer activities.

Yes, I give my permission for my child to be photographedNo, I do not give my permission for my child to be photographed

I understand that students will be responsible for the cost of field trip activities. Please enter your name below to acknowledge the above.*

Completion of Application. *

Date

NCSO Law & Leadership Summer Enrichment Program Application

Student INFO:

FATHER INFORMATION:

MOTHER INFORMATION:

Emergency Contacts Info

MEDICAL INFORMATION

BEHAVIORAL CONSIDERATIONS

Emergency Medical Authorization Pt.1

Emergency Medical Authorization Pt.2

Parental Acknowledgment

BEHAVIORAL PLAN

By a child performing any of the acts above, this could cause serious harm to another child or teacher. NCSO staff will document anytime an occurrence occurs.

PHOTO RELEASE AGREEMENT