Language Learning Institute in Brown School Summer Camp Registration Form

PLEASE PRINT THIS PAGE, COMPLETE IT AND SEND IT, ALONG WITH A CHECK MADE PAYABLE TO THE LANGUAGE LEARNING INSTITUTE, TO THE LANGUAGE LEARNING INSTITUTE, PO BOX 12743, ALBANY NY 12212

Registration Form Language Learning Institute in Brown School Summer Camp

Please place a check mark next to the camp(s) in which you are enrolling your child:

All camps are for children going into the First through Fifth Grades

______ Italian (July 20 – July 24) 1:30 to 3:30pm                  $150 materials included

______French (July 27 – July 31) 9:30 to 11:30am               $150 materials included

______Heritage Chinese

(August 10 – August 14) 1:30 to 3:30pm                                $150 materials included

 

Child’s Name _________________________________________________________

Child’s Age _______________Going into ____________grade

Child’s School Name and City ____________________________________________

Parent’s Name ________________________________________________________

Parent’s Address ______________________________________________________

Home Phone: _______________________ Cell ______________________________

Email ________________________________________________________________

Emergency Contact Name _____________________________________________________________________

Emergency Contact Phone Number _____________________________________________________________________

Child’s Health Information:

Allergies ____________________________________________________________________________

Vaccinations ________________________________________________________________________

Doctor _____________________________________________________________________________

Doctor’s Phone Number ______________________________________________________________

Please indicate if your child has:  (Check all that apply and describe below.)

Asthma              _____               Seizures         _____            Last Tetanus   _____   Other ___

Severe Allergy   _____               Diabetes         _____

History of Surgery (describe) ___________________________________________

Other Allergies _____               Special Diet   _____             Physical Limitations      _____

Please indicate if your child has:  (Check all that apply and describe below.)

Does your child require special services?        Yes_____     No_____

If so, is aide/shared aide services included?    Yes_____     No_____

Will medication be required during camp?      Yes_____     No_____’

Describe:

If medication is needed at camp the following is required: A doctor’s order and written parental permission must be on file with The Language Learning Institute.

Self- directed students who have permission to self-carry may do so with the medication in the original labeled container. If the self-directed student does not have permission to self-carry, the teacher will need to carry the medication.

I hereby grant permission for The Language Learning institute camps and its employees full authority to take whatever action they deem necessary regarding my child’s health and safety in the event I cannot be reached or in a situation where time is of the essence; and fully release The Language Learning Institute Camps and its employees from any liability in connection with those decisions.  I grant permission for emergency treatment by a rescue squad, private physician and/or hospital or emergency health care facility staff if needed.  Any such action will be taken in the best interests of my child and will be reported to me as soon as possible.

My signature gives permission for any medical action

__________________________                 _____________________

Parent Signature                                             Date