Michael Hearts Academy "Home Away From Home" Registration Form
*Required Fields
Student Information
*Name:
*
SS#:
*Date of Birth:
*
-
Month
-
Day
Year
Date
*Gender:
*
*Disability Documentation:
*
*Home address:
*
*City:
*
*Zip Code:
*
*County:
*
*Phone Number:
*
Format: (000) 000-0000.
Email:
example@example.com
*Name of School:
*
Parent/Guardian Information (if applicable)
Name:
Home Phone, if different from student:
Format: (000) 000-0000.
Cell:
Format: (000) 000-0000.
Email:
example@example.com
*Person Making Referral
Name:
Relationship to student:
Email:
example@example.com
Phone:
Format: (000) 000-0000.
Accommodations for initial meeting with MHA Staff:
Yes
Yes
Yes
Yes
Yes
If yes, please explain:
5104 North Orang Blossom Trail #220 Orlando FL 32810 Ph: 407.223.0949
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FIELD TRIP
Parental/Guardian Consent Formand Liability waiver
Participant's / Child's Name:
Birth Date:
-
Month
-
Day
Year
Date
Work Phone:
Format: (000) 000-0000.
Participant's / Child's Name:
Parent/Guardian's Name:
Home Address:
Home Phone:
Format: (000) 000-0000.
e-Mail:
example@example.com
I (Parent/Guardian)
(Child's Name)
grant permission for my child, to participate in this field trip with
Michael Hearts Academy
, which includes transportation. This activity will take place under the guidance and direction of employees and/or volunteers.
As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor participant's agree on behalf of myself, my child named herein, or our heirs, successors and assigns, to hold harmless and defend the Organizer its officers, directors and agents, and my own representatives associated with the event, from any and all actions, claims, demands, damages, costs, expenses and all consequential damage arising from or in connection with my child attending the event or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the Organizer, its officers, directors and agents, or representatives associated with the event for reasonable attorney's fees and expenses arising therewith.
Signature of Parent/Guardian/Application
Date
-
Month
-
Day
Year
Date
5104 North Orange Blossom Trl #220 Orlando, Fl 32810 407.223.0949ph 407.877.2031fx
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MICHAEL
ACADEMY
Medical Matters:
I hereby warrant that to the best of my knowledge, my child is in good
health and assumes all responsibility for the health of my child.
Emergency Medical Treatment:
In the event of an emergency, hereby give permission to transport my child to a hospital for
emergency medical or surgical treatment. Wishes are advised prior to any further treatment by
the hospital or doctor. In the event of an emergency and you are unable to reach me at the
above numbers, contact:
Name:
Phone:
Format: (000) 000-0000.
Relationship:
Phone:
Format: (000) 000-0000.
Family Doctor:
Family Health Plan Carrier:
Policy#:
Specific Medical Information: The Organizer will take reasonable care to see that thefollowing information will be held in confidence:
Allergic reactions (medications, foods, plants, insects, etc.):
Immunizations-date of last tetanus/diphtheria immunization:
Does child have a medically prescribed diet?
Any physical limitations?
Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, bedwetting, fainting?
Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc.? if so, date and disease or condition:
5104 North Orange Blossom Trl #220 Orlando, Fl 32810 407.223.0949ph 407.877.2031fx
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You should be aware of these special medical conditions of my
child:
Life skills:
Can camper use bathroom independently?
Yes
No
Please explain if need special assistance in the bathroom:
Can camper feed himself/herself independently?
Yes
No
Please explain if special assistance is needed with eating (example, food cut-up):
*Disability Documentation
In accordance with the requirements identified by Michael Hearts Academy, one of the following documents MUST be submitted with the Registration. Please check off as attached:
Current IEP
Current 504 Plan
Behavior Plan
Other documentation stating students are being served as a student with a disability
All payments are due in advance of service.
Payments for summer camp must be paid on Monday of each week. For any fees, a $25 late fee will apply.
All camp fees are non-refundable once a camper is accepted to any session. No refunds or credits are given. Camper submits an application along with payment and the camper is deemed ineligible to attend Camp by Michael Hearts Academy management, the deposit check, and any other funds, will be returned in full. Camper fails to complete any camp session; no refund or credit will be given. All camp fee payments will be forfeited for campers who fail to attend assigned session(s).
Guarantee of payment: For and in consideration of services rendered or to be rendered I hereby agree to pay any and all camp fees listed on this form. I understand and agree that all bills are payable and become due upon presentation.
Signature of Parent/Guardian/Application
Date
-
Month
-
Day
Year
Date
5104 North Orange Blossom Trl #220 Orlando, Fl 32810 407.223.0949ph 407.877.2031fx
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MICHAELACADEMY
All information in the above application is correct to the best of my
knowledge. I understand that through Michael Hearts Academy, campers
are offered different Social Skills with multiple activities in the community,
which can help campers explore, prepare for, and make informed life decisions. I understand
that I must be an active participant in the services I choose to achieve.
Signature of Parent/Guardian/Application
Date
-
Month
-
Day
Year
Date
Photograph/image consent
Michael Hearts Academy would like your permission to use images/photos that may include
camper. I hereby grant permission to Michael Hearts Academy to photograph and video me,
and otherwise capture my image, and to make recording of my voice. I further grant to Michael
Hearts Academy right to reproduce, use, exhibit, display, broadcast and distribute these images
and recording in any media now known or later developed for promoting, publicizing or
explaining Special Hearts Farm and its activities. Photographs, video images and voices
recordings are the property of Michael Hearts Academy.
Signature of Parent/Guardian/Application
Date
-
Month
-
Day
Year
Date
Should be Empty: