Shen Summer Adventures 2014 Language Exploration Camp Registration Form

SHEN SUMMER ADVENTURES 2014

REGISTRATION MARCH 1-JUNE 13*

*$10.00 late fee will be charged after JUNE 13

 

The Language Learning Institute Summer Language Exploration Camp

(Grades 1-5)   8:30am-12:00pm

___July 7-11 ___ July 14-18 ___July 21-25

Fee: $120.00/wk   $130.00 (after June 13)*

Language:  ____ French      _____ Spanish     _____Chinese

______YES! I want to make this camp a full day!

   Additional Fee:  $100 Fee per week per child

PLEASE NOTE THAT THIS OPTION IS FIRST COME, FIRST SERVE. We Can only accommodate 12 CHILDREN PER WEEK WITH THE FULL DAY OPTION.

 

Student’s Name__________________________________________________________

Grade student will be entering in September_____

Parent/Legal Guardian Name(s)______________________________________________

Street ________________________City ________________Zip code_______

Daytime Phone ___________   Email________________________________

 

For the safety of your child, all campers MUST have a completed health form Health Form. Please complete the health form which follows and send both the completed registration and health forms along with a check.

 

Please make checks/money orders (cash is not accepted) payable to:

“The Language Learning Institute” and mail to:

The Language Learning Institute                                            

PO Box 12743                                                              

Albany, NY 12212                                                        

 

Questions?      Please call 518-346-7096        We are here to help. 

 

 Shen Summer Adventures Health Form

Please complete the following health form and submit with your registration form for any of the Shen Summer Adventures camps.  We require only one health form per child.  A consulting nurse will be reviewing the health forms prior to the start of camps.

Please note that there will not be a nurse on site during the weeks that camps are in session.

 

Student’s Name ____________________________________

Entering grade_____(Fall 2014)

Birth date ____________________

Street_____________________________City______________________

Zip code_________

Email__________________________________________________

School attended last year___________________________________

 

Camp Name(s) & Date(s) Attending______________________________________________________

 

Parent/Legal Guardian ______________________________

Home ph_ __________

Daytime/cell ph_______

Family Physician ___________________________________Ph________________

If Parent/Legal Guardian cannot be reached in an emergency, please contact:

Name___________________________________  Ph________________________

Name____________________________________

Ph________________________

 

I hereby grant permission for Shen Summer Adventures 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 Shen Summer Adventures 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.

 

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 Shen Summer Adventures.

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.

 

My signature gives permission for any medical action

__________________________                 _____________________

Parent Signature                                             Date