Legacy Scholars Summer Camp
Parent Enrollment Form
Child’s Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Please Select
Male
Female
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Parent / Guardian Information
Parent/Guardian Name
*
First Name
Middle Name
Last Name
Relationship to Child
*
Phone Number
*
Email Address
*
example@example.com
Employer (optional)
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Emergency Contacts (Other than Parent)
Name
*
Phone Number
*
Name
*
Phone Number
*
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Authorized Pick-Up Persons
Photo ID required for pick-up.
Name
*
Phone Number
*
Name
*
Phone Number
*
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Health Information (Florida Child Care Requirement)
Medications required during camp (attach form if applicable)
Primary Care Physician
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Allergies (food, medication, environmental)
Chronic conditions / special needs
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Consent & Authorizations
Acknowledgements
I have received and agree to follow the Legacy Scholars Summer Camp Parent Handbook. I understand camp hours are 8:00 a.m. – 5:00 p.m.
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
Staff Use Only: Date Received
-
Month
-
Day
Year
Date
Approved By
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Submit
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