2012 Summer Camp registration form by vSTnB6


									                                   Mill Grove United Methodist Church
                                  Children’s Ministries Preschool
                                            7311 Mill Grove Rd., Indian Trail, NC 28079
                                            704-681-8608 www.millgrovepreschool.com

                                          Summer Camp
                                      Welcome to Summer Fun 2012!

We are offering five 2-week sessions for all children ages one year through rising sixth grade. Each Session
will have fun filled themed activities geared toward each age group. Arts, crafts, games, stories, music,
adventures, inventions and much more!

All sessions run Monday thru Thursday, 9:00am – 1:00pm.

I would like to register my Camper for the following sessions
                 Session 1: June 4th - June 15th            $120         Wild West Fest
                                     th         th
                 Session 2: June 18 - June 29               $120         Beyond the Gold – Mega Sports
                 Session 3: July 9th – July 20th            $140         Iron Chef Kids (lunch is included for
                                                                         this session)
               Session 4: July 23rd – August 3rd           $120          Rock for Kids
               Session 5: August 6th – August 17th         $120          Mad About Science

There is a one time, non-refundable $25 registration fee. All fees must be paid in advance of each session,
they are non-refundable and cannot be pro-rated.

Student’s Name                                       Date of Birth                           Gender
Address                                              City                                    Zip

Home Telephone                                       Email Address
Mom Cell                                             Dad Cell
Other Emergency number(s)

About your camper 
Are immunizations current? Yes                 No
Any known allergies? Yes               No       If “Yes”, please explain
                                                         Is an Epipen required? Yes             No
Our Summer Camp can involve both vigorous and quiet indoor and outdoor play; please indicate any
limitations that your child may have

Other things we should know

                                        *Special Summer notes:
Each day, please …. apply sunscreen to your camper prior to their arrival at camp.
                 …. send your camper with a hat and closed toe shoes, we don’t want unhappy feet.
                 …. send a water bottle, and a packed snack and lunch (except for Session 3:Iron Chef
         **********Please complete both sides of this form **********
                                     2012 Summer Camp
                                              Permissions Form

Camper’s Name

Your Name and Relationship to Camper

Refund and Withdrawal Policy
The Registration fee is non-refundable, unless class enrollment minimum is not met or placement is
unavailable. Session tuition is due on the first day of camp. If a child must be withdrawn from the program,
please note that any attendance during the session constitutes a full session.

Consent for Child to be photographed for Preschool/Church use only
I, the undersigned, do hereby grant permission for my child to be photographed and/or videotaped during
preschool events or parties, and for use in crafts projects and/or online photo gallery. If I have any concerns
regarding photography, I will address this concern with the Preschool Director.

Emergency Information
Child’s Physician                                                   Phone
Insurance Company                                                   Phone
Emergency Room Preference

Permission for Health Care
        I, the undersigned, do hereby verify and grant permission that in the event my child should require
medical attention while in the care of Children’s Ministries Preschool staff during Preschool hours or events, I
hereby authorize the staff of Children’s Ministries Preschool to procure and/or provide such emergency
medical attention for my child. I understand that all costs that may be incurred by such emergency medical
attention will be my responsibility. I hereby release Children’s Ministry Preschool and Mill Grove United
Methodist Church and its staff from any legal consequences that might result from such emergency attention.
This authorization is valid for one year from date of signature unless Children’s Ministries Preschool is
otherwise notified in writing.

Persons designated for pick up (other than those listed on registration form)
        I, authorize that my child can be released by Children’s Ministries Preschool Summer Staff to the
following persons. I also agree to inform such persons that they must possess a valid Government issued
picture ID for the persons listed below:

Name                                         phone                          relationship to child
Name                                         phone                          relationship to child
Name                                         phone                          relationship to child

Signature of Parent of Legal Guardian
By signing below, I do agree/approve and consent to all information on this registration form. I will advise
MGUMCP of any changes in phone or address information. If I am the child’s Legal Guardian< I will provide
documentation to MGUMP to prove such.

Signature                                                           Date

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