St. Paul's Explorers Preschool 2019 Summer Camp Enrollment Form
Student's First Name: *
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Student's Last Name: *
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Student's Nickname
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Student's DOB: *
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Student's Camp Shirt Size ( runs small): *
Explorers Camp- Week 1 (July 8th-12th)
Explorers Camp- Week 2 (July 15th-19th)
Explorers Camp- Week 3 (July 22-26)
Explorers Camp- Week 4 (July 29th-Aug 2)
Explorers Camp- Week 5 (Aug 5th-9th)
Explorers Camp- Week 6 (Aug 12th-16th)
Explorers Camp- Week 7 (Aug 19th-23rd)
Does your child have any allergies/or special needs ( Emergency Allergy medication requires a EACP form. Pls contact us): *
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Pediatrician or Primary Care Physician Name/Number: *
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Pediatric Dentist Name/Number: *
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Family Health Insurance Name/Group #: *
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Primary Parent/Guardian Name: *
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Primary Parent/Guardian Email: *
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Primary Parent/Guardian Cell #: *
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Primary Parent/Guardian Home Address: *
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Secondary Parent/Guardian Name: *
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Secondary Parent/Guardian Email: *
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Secondary Parent/Guardian Cell#: *
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Other Emergency Contact Name & Cell#:
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Other Authorized Adults drop-off/pick-up ( Include name/cell #)
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I agree to submit my child's current Vaccination Record/Proof of identity ( passport or birth certificate) prior to camp and understand that camp tuition is due upon receipt of camp invoice and must be paid prior to your child's first day of camp. Families wishing to enroll in a payment plan must email us for approval. Registration Day to drop off documents, if not emailed in advance is JUNE 24. *
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“ I certify that all of the information I have provided is complete and accurate. I grant permission for my child to participate in all activities and programs during St. Paul’s Explorers Summer Camp. I understand that St. Paul's Explorers Programs are operated by St. Paul's Episcopal Church in Alexandria, Virginia. I agree to be billed the program fees via electronic invoice and to pay the fee as outlined in the Camp Tuition Schedule. I agree to provide 7 days notice to Director, via email, if I intend to withdraw from the St. Paul’s Explorers Summer Camp program. I understand that no refunds will be given for pre-paid Camp tuition or deposit. I agree to update the Director of any changes to my child's health condition or their ability to participate prior to them attending the St. Paul’s Explorers Programs. I agree that my children are to follow the directions of all Explorers staff, including safety procedures and behavioral guidelines. I agree to communicate via email, with the Director, any issues or concerns during the St. Paul’s Explorers Summer Camp Program. I agree to support the decision of the Director in regards to my child's continued participation in the St. Paul’s Explorers Programs. I agree to be reachable via the above listed cell phone number-during all program hours while my child is participating in St. Paul’s Explorers Programs. I grant permission, in absence of my ability to provide immediate supervision of my child during a medical/health emergency, for the Director and Staff to seek emergency medical care for my child. This includes transportation, if necessary, by ambulance to the nearest hospital. I agree to provide active medical/health insurance coverage for my child during their participation in St. Paul’s Explorers Summer Camp Program. I agree to provide any emergency allergy medication/ Anaphylaxis device to the Director for the use in an emergency, as prescribed for my child by their physician (separate Emergency Allergy Care Plan required). I agree to abide by all program policies and procedures during my child's participation in St. Paul’s Explorers Summer Camp Program. “ ********** Primary Parent/Guardian Electronic Signature below constitutes agreement of this Summer Camp contract for 2019**********: *
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