Little Prince and Princess's Learning Center Summer Camp

- Child's Full Name
  
  First NameMiddle NameLast NameSuffix
- Birth Date
  
  MonthDayYear
- Gender
  
  MaleFemale
- Child's Full Name
  
  First NameMiddle NameLast NameSuffix
- Birth Date
  
  MonthDayYear
- Gender
  
  MaleFemale
- Child's Full Name
  
  First NameMiddle NameLast NameSuffix
- Birth Date
  
  MonthDayYear
- Gender
  
  MaleFemale
- Child's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Child's Phone Number
  
  Area CodePhone Number
- Current Grade (separate with comma for more than one child)
- Attending School (separate with comma for more than one child)
- Information about your child: (list allergies, restrictions, special needs, medication)
- Parent 1
  
  PrefixFirst NameMiddle NameLast NameSuffix
- E-mail
- Phone Number
  
  Area CodePhone Number
- Work Number
  
  Area CodePhone Number
- Phone Number
  
  Area CodePhone Number
- Cellphone Number
  
  Area CodePhone Number
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Parent 2
  
  PrefixFirst NameMiddle NameLast NameSuffix
- E-mail
- Phone Number
  
  Area CodePhone Number
- Work Number
  
  Area CodePhone Number
- Cellphone Number
  
  Area CodePhone Number
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Doctor's Name
  
  First NameLast Name
- Insurance Company
- Policy Number
- Does your child have allergies and/or intolerance to food, medication or any other substances? What are the symptoms and action to be taken if any?
- Does your child have any conditions that would prevent them from performing in summer camp and are any accomodations needed?
- I give permission for my child to view G or PG rated movies
  Parent's Intial
- I give permission to LPPLC to apply non-medical prescription cream, sunscreen, insect repellant or ointment on my child while in attendance if needed.
  Parent's Initial
- I give permission to be transported by Little Prince and Princess's staff and volunteer vehicles and to participate in all LPPLC summer program activities and related field trips.
- Diagnosed delays, IEP, Special accommodations?
- Fees will be paid by:
  
  Parent PayState FundingOther
- Authorized Pickup 1
  
  PrefixFirst NameMiddle NameLast NameSuffix
- Phone Number
  
  Area CodePhone Number
- Authorized Pickup 2
  
  PrefixFirst NameMiddle NameLast NameSuffix
- Phone Number
  
  Area CodePhone Number
- Authorized Pickup 3
  
  PrefixFirst NameMiddle NameLast NameSuffix
- Phone Number
  
  Area CodePhone Number
- Informed Consent & Acknowledgement
- I hereby give my approval for my child’s participation in any and all activities prepared by Little Prince and Princess's Learning Center Summer Camp during the selected camp. In exchange for the acceptance of said child’s candidacy by Little Prince and Princess's Learning Center (LPPLC). I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Little Prince and Princess's Learning Center (LPPLC) 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 Little Prince and Princess's Learning Center (LPPLC), 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.
  
  Parent Signature _________________________Date _______________
- Medical Release and Authorization
- As Parent and/or Guardian of the named child above, 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 child. 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 Little Prince and Princess's Learning Center (LPPLC) and its affiliates including Directors, Coaches, and Volunteers or Parents 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 session.
  
  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.
  
  Parent Signtature________________________________Date _________________________
- Liability/Photo/Video Release
- I _____________________am a parent or legal guardian of the registered who is currently under the age of 18, grant permission for the registered camper to attend Little Prince and Princess's Learning Center (LPPLC) and consent to its Discipline Policy and also do hereby release Little Prince and Princess's Learning Center (LPPLC) from any and all liability or responsibility due to any injury that he/she/I may incur as the result of, or arising in any way from participation in activities at or under the direction of Little Prince and Princess's Learning Center (LPPLC). I am fully aware and consent to accept these risks and voluntarily agree to allow his/her participation in activities. If I cannot be consulted in an emergency, I hereby give permission to the physician selected by a representative of Little Prince and Princess's Learning Center (LPPLC) to hospitalize, secure treatment for, and to order injections, anesthesia, and/or surgery for the person named above. I understand that Little Prince and Princess's Learning Center (LPPLC) only carries secondary insurance and that I will take primary responsibility for any fees or charges at any clinic, facility, or hospital arising from treatment of injury or illness. I furthermore understand Little Prince and Princess's Learning Center (LPPLC) often takes photographs or videos of participants during its activities or events. I grant permission without compensation that these photographs or videos may be used in publications, presentations, websites or promotion of Little Prince and Princess's Learning Center (LPPLC). Little Prince and Princess's Learning Center (LPPLC) will not identify me or my child by name, or release any other personal information without additional written permission from me.
  
  Parent Signature__________________________Date ____________
- Confirmation*
  
  Informed Consent & AcknowledgementMedical Release & AuthorizationLiability/Photo/Video Release
- 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.
- Enter the message as it's shown*
- By signing I am acknowledging that I have all terms and I am agreeing for my child to participate in Little Prince and Princess's Learning Center Summer Camp program
  
  Clear
- Should be Empty:

Informed Consent & Acknowledgement

Medical Release and Authorization

Liability/Photo/Video Release