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2020 Summer Camp Registration Form

For children ages 6 through 9/10 

Please print this form, complete it  with a check made to The Language Learning Institute

Please mail the registration form and payment to:

The Language Learning Institute, 3 Lear Jet Lane Suite 102A, Latham, NY 12110

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

These Camps run Monday through Friday: 2 hours each day

______Learn to Speak French : 9:00 to 11:00am  Week of August 10th      

Fee: $470       $20 sibling discount $450 each additional child

______Learn to Speak Spanish : 9:00am to 11:00am   Week of August  17th 

Fee: $470       $20 sibling discount $450 each additional child      


These camps are held at The Language Learning Institute. 3 Lear Jet Lane, Suite 102A in Latham 

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_____’


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