CHILD’S APPLICATION FOR ENROLLMENT

To be completed, signed, and placed on file in the facility on the first day and updated as changes occur and at least annually

CAMP SELECTION

Which camp would you like to register for?

Does your child have previous French experience?

YesNoA little

CHILD INFORMATION

Date of Birth

Full Name (Last, First, Middle, Nickname)

Child's Address

FAMILY INFORMATION

Child lives with

Parent / Guardian 1

Name

Home Phone

Cell Phone

Address (if different from child's)

Zip Code

Work Phone

Parent / Guardian 2

Name

Home Phone

Cell Phone

Address (if different from child's)

Zip Code

Work Phone

AUTHORIZED PICK-UP & EMERGENCY CONTACTS

Child will be released only to the parents/guardians listed above. The child may also be released to the individuals listed below. In an emergency, if parents/guardians cannot be reached, the facility may contact:

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

HEALTH CARE NEEDS

Medical action plan attached?
YesNo

Allergies (symptoms & response)

Health Concerns (symptoms & response)

Behavior / Fears

Medications

Other Important Medical Information

EMERGENCY MEDICAL CARE

Doctor Name

Doctor's Office Phone

Hospital Preference

Hospital Phone

I, as the parent/guardian, authorize The Académie to obtain appropriate medical attention for my child in the event of an emergency.

Parent / Guardian Signature

Date

Open Houses

CHILD’S APPLICATION FOR ENROLLMENT

CAMP SELECTION

CHILD INFORMATION

FAMILY INFORMATION

Parent / Guardian 1

Parent / Guardian 2

AUTHORIZED PICK-UP & EMERGENCY CONTACTS

HEALTH CARE NEEDS

EMERGENCY MEDICAL CARE

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