Summer Registration Form | Exploration AfterSchool

Parent/ Guardian First & Last Name

Email

Phone Number

Child's First & Last Name

Add additional children under same parent/ guardian/ authorized representative(s)?

Yes

No

How may we release your child(ren) from Exploration Camp at the end of each day?

Parent/ guardian/ authorized representative pickup

Child is free to go home unaccompanied

Other

NAME & PHONE NUMBER of all persons authorized to take your child(ren) from the camp. NOTE: Child(ren) will not be allowed to leave with any other person without written authorization from parent/ guardian or authorized representative.

Exploration Camp Session(s) Requested

Session 1: Jun 22-26$675

Session 2: Jun 29-Jul 3$675

Session 3: Jul 6-10$675

Session 4: Jul 13-17$675

Does your child/ren have special needs?

Yes

No

Please note any food allergies that we should be aware of for your child/ren. (If no known allergies, please write "None".)

Consent for Emergency Medical Treatment

I consent

As the parent or authorized representative, I hereby give consent to Play-Learn-Live (Exploration AfterSchool and/or Exploration Camp) to obtain all emergency medical care prescribed by a duly licensed physician (M.D.) or osteopath (D.O.) for the child(ren) registered. This care may be given under whatever conditions are necessary to preserve the life, limb, or well being of the child.

Waiver & Release of Liability (link below)

I agree and approve

https://docs.google.com/document/d/1NONVVyWYDGXDrQkslcAzqasyYz-49b6ytnRaKHC9w00/edit?usp=sharing

Acknowledgment of Understanding - By checking the box, you agree to have read the linked Waiver and Release of Liability and fully understand its terms. You understand that you are waiving certain legal rights, including the right to sue the Releasees. You approve this Agreement freely and voluntarily on behalf of yourself and your child.

Signature

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I hereby certify that the information provided above is true and accurate to the best of my knowledge.

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