Camp Enrollment Form - Acorn Learning Center

Enrollment Form
Official Use only: Entry Date_________ Exit Date_________
Preschool only ___ Childcare only ___ Preschool plus ___ Afterschool Only ___
Child’s name
Last
First
Middle
Street Address
Parent/guardian name
Home phone
Street Address
Parent/guardian name
Home phone
Street Address
Nickname
birthdate
City
Zip
Cell phone
Alternative phone
City
Zip
Cell phone
Alternative phone
City
Zip
The following people may pick up my child.
Name:
Home:
Relationship:
Cell:
Alternative:
Name:
Home:
Relationship:
Cell:
Alternative:
In the case of an emergency, I give my permission for any of the following individuals to be contacted and my child may
be released to any of them. _________________________________________
Parent signature
Name:
Home:
Relationship:
Cell:
Alternative:
Name:
Home:
Relationship:
Cell:
Alternative:
Consent to medical care and treatment of minor children
I give permission that my child ___________________________, may be given first aid/emergency treatment by a
qualified staff person at Acorn Learning Center.
______________________________________________ ______________________________________________
Parent/guardian signature
Date
Parent/guardian signature
Date
When I cannot be contacted or reached, I authorize and consent to medical, surgical and hospital care, treatment and
procedures to be performed for my child by a licensed physician, healthcare provider, hospital or aid car attendant when
deemed necessary or advisable by the physician or aid car attendant to safeguard my child’s health. I waive my right of
informed consent to such treatment. I also give my permission for my child to be transported by ambulance or aid car to
an emergency center for treatment. I certify under penalty of perjury under the laws of the State of Washington that
this information is true and correct.
______________________________________________
______________________________________________
Parent/guardian signature
Has your child ever been in care before?
If yes, where?
Date
Parent/guardian signature
Date
About your child
Has there been any recent situation the child has been
exposed to recently? (death, moving, divorce, etc)
What is your normal method of discipline?
What is your child’s temperament?
Does your child have any food restrictions?
Is your child potty trained? If yes, can your child be relied
upon to indicate bathroom needs?
Does your child have any siblings?(Please list names and ages)
Does your child have any favorite books, toys, or outdoor
activities? If yes, please list.
What language is spoken at home?
Does your child have any security objects such as a blanket
or pacifier?
Camp Selection
Please check all that apply
Animal*
Art*
Literacy
Cooking
July 6 - July 9
July 13 - July 16
July 20 - July 23
July 27 - July 30
Please specify which days you
would like if choosing less than 4
days a week.
4__ 3___2___
4__ 3___2___
4__ 3___2___
4__ 3___2___
Full day___ AM Half Day___PM Half Day___
Full day___ AM Half Day___PM Half Day___
Full day___ AM Half Day___PM Half Day___
Full day___ AM Half Day___PM Half Day___
Camp Costs Per Week
4 Days a week
3 days a week
2 days a week
Full Day
Half Day
Full Day
Half Day
Full Day
Half Day
6 weeks – 18 $200
$140
$160
$110
$115
$75
months
18 months – $180
$135
$150
$100
$110
$70
3 yrs
3 years and
$170
$120
$135
$90
$95
$65
up
Hourly
$10
$9
$8
* Camp has a $10 field trip fee in addition to weekly camp costs.
**Payments must be made two weeks prior to the camp start date. Checks, money orders, and cash are accepted as
payment. Checks and money orders can be made out to TLC with your child’s name in the memo. A $15 non-refundable
registration fee is due per camp at the time of registration. This will be placed towards your balance due at the time of
payment. If payments are not received two weeks prior to your child’s camp start date, your child’s spot may be given
away and you will not receive a refund of your registration fee.