SUMMER 2011 MINI-CAMP REGISTRATION FORM
ONCE UPON A TIME.....
M Mini-Camp Week 1 - June 28-June 30 - Fantastic Fossils
Mini-Camp Week 2 – July 5-July 7 - Magical Kingdom
Mini-Camp Week 3 – July 12-July 14 - Playful Pirates
Mini-Camp Week 4 – July 19-July 21 - By The Beach
PLEASE CHECK THE WEEK/WEEKS YOU ARE REGISTERING FOR.
Child’s Name________________________________________Age______Birthdate__________
Name of Parent or Legal Guardian__________________________________________________
Address_______________________________________________________________________
City_________________________________________State_________ZIP_________________
Phone (home)______________________________Phone(cell)___________________________
Email Address__________________________________________________________________
Emergency Contact (other than parent)______________________________________________
List any allergies or medical conditions_____________________________________________________________________
_____________________________________________________________________________
Forms are available upon request.
Are there any pertinent medical conditions that we should be aware of? Yes_____No_____
If yes, please explain_______________________________________________________________________
_____________________________________________________________________________
There will be Epi-pen/CPR/First Aid trained and experienced teachers with the children at all times. Participation in any physical activity may involve risk of injury. As a parent or guardian, I am aware of these hazards and my child’s ability to participate. I understand that Stephanie Letizia and Kathye Flanagan may not be held legally responsible for any injuries or accidents that may occur. This program is fully insured.
Signature
_____________________________________________Date____________________
For more information or questions please contact Kathye at 430-5534, email kathyeflngn@yahoo.com or Stephanie Letizia at 436-2874 email teach2kds3@aol.com.
