Registration Form for Grammar and Writing: Language Learning Institute, Latham NY

PLEASE PRINT THIS FORM, COMPLETE IT AND SEND IT TO:

THE LANGUAGE LEARNING INSTITUTE, PO BOX 12743, ALBANY, NY 12212 WITH PAYMENT

PLEASE PAY BY CHECK: PAYABLE TO: THE LANGUAGE LEARNING INSTITUTE

THANK YOU.

2017 Registration Form Language Learning Institute:  Latham, NY (for kids going into 8th grade and older)

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

English Grammar and Effective Writing: Grades 8 through 12

_____   Week 1     July 17-20          9:00 to 11:00am          $400 plus $15 for  materials 

.

_____   Week 2     August 7-10        2:00 to 4:00pm         $400 plus $15 for  materials 

.

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