How did you hear about Study Buddies AFTER SCHOOL @ NOMAD? *

Child's Gender *

FIRST NAME (Child) *

LAST NAME (Child) *

Child's date of birth *

Grade & School Attending *

Choose your Days (complete each row) *

BUS TRANSPORTATION AVAILABLE: Are you interested in pick-up between 7a-8a ($12 per day or $50 "bus pass" through Feb/Presidents' Day) from:

Parent/Guardian First and Last Name *

Parent/Guardian Street Address *

Parent/Guardian Contact Phone Number(s) *

Additional Parent email (optional)

Emergency Contact First and Last Name *

Emergency Contact Contact Number *

Emergency Contact Relationship to Camper *

Please list those people in addition to Parent/Guardian that are permitted to pick up your camper and their phone number and email address:

Please tell us a little about your campers swim experience and ability level. *

Medical Information: Name of Insurance Provider & Policy Number *

Medical Information: Primary Physician *

Please list ANY allergies that your camper has to any food, medications or environmental factors.

Please list and describe any health issues, medical conditions and/or physical concerns, as well as, any current medications.

Please list anything else you would like us to know about your child.

Terms of Agreement: NOMAD Aquatics & Fitness and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness with accompanying physician's note. Children's photos and quotes may be used for publicity purposes, In case of an emergency, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or physician). Please initial below. *

Photo Release: I hereby give permission for my child to be photographed at NOMAD Aquatics & Fitness. I understand the photos will be used for promotional purposes. I understand that although my child's photograph may be used for advertising, his or her identity will not be disclosed. I do not expect compensation and that all photos are property of NOMAD Aquatics & Fitness and its affiliates. Please initial below. *

Guardian Signature *

$25 Registration Due - covers 1 year of programs (camps & lessons) *

$20 Deposit Due - for each day selected *

Payment Options: *

Enter Method of Payment (ACH - Bank Name, Routing, and Account number OR CC info with date of expiration and CVV code). If entered for another child, please type "provided". *

I authorize NOMAD Aquatics & Fitness to draft my CC or make an ACH DRAFT for a registration fee (if due) and camp deposit ($20 per day) that is not refundable. The balance will be due 2 days prior to camp start and will be automatically drafted by the method selected above if a check is not presented before that time.

Printed Name of Parent/Guardian *

Date Submitted *