WOM Charter School Summer Camp 2017 Registration Form
Camp Address: Willow Oak Montessori Charter School
50101 Governor's Drive, Suite 170, Chapel Hill, NC 27517

All enrolled children are welcome to join us for our community lunch from 12:00-12:30. Please pack a lunch, snack and water bottle for the morning and/or afternoon sessions.

Pricing: Early Bird (by Feb. 15): $137.50/week for half day. $275/week for full day.
After February 15: $150/week for half day. $300/week for full day.

Child's First Name
Your answer
Child's Last Name
Your answer
Child's Birth Date, MM/DD/YYYY
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Camp Sessions
Required
Parent 1 Name
Your answer
Parent 1 Day Time Phone
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Parent 1 Cell Phone Number
Your answer
Parent 2 Name
Your answer
Parent 2 Day Time Phone
Your answer
Parent 2 Cell Phone Number
Your answer
Parent Email(s)
Your answer
Child's Allergies/Medical Conditions/Other Special Needs or Considerations
Your answer
Summer Camp Policies
Cancellations made after May 15th will NOT be eligible for a refund. Camp sessions are subject to cancellation by Willow Oak Montessori. If Willow Oak Montessori cancels a session, all fees will be refunded. A $10 late fee will be charged for each 10 minutes a child is picked up late from camp. Written authorization is required for anyone other than a parent/guardian listed above to pick up a camp participant. By entering your name in the space below, you are agreeing to these Summer Camp Policies.
Your answer
Release and Hold Harmless Agreement and Consent for Medical Treatment
As part of the consideration for my child’s participation in the Willow Oak Montessori Charter School Summer Camp program, I hereby release, hold harmless, and forever discharge Willow Oak Montessori Charter School, Inc. (the “School”), its employees and agents from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, property damage, or personal injury, including death, that may be sustained by me or my child or to any property belonging to me or my child while my child is participating in the program, except for damages caused by the negligence of the School, its agents and employees. I am fully aware of the risks and hazards associated with this program. I acknowledge that my child’s participation in this activity is elected by me and not required. I voluntarily assume full responsibility for any risk of loss, damage, or personal injury, including death, and for any property damage that may be sustained by me or my child as a result of my child’s participation in this program. In the event of illness or injury, I hereby authorize School staff with current Red Cross first aid certification to administer first aid to my child, and I hereby authorize School staff to obtain emergency medical treatment for my child at UNC Hospitals as deemed necessary, including administration of an anesthetic or other medication and surgery, and I hereby assume the cost of such treatment. I understand that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of the School to give specific consent to the diagnosis, treatment, or hospital care which in the best judgment of a licensed physician is deemed advisable. I understand that the School will make best efforts to notify me immediately should emergency treatment for my child become necessary. I also grant permission for emergency CPR to be administered to my child by a certified person should it become necessary. I have read and I understand this document, including the release and hold harmless portions of it. I understand and agree that it is binding on myself, my child, our heirs, assigns, and personal representatives. By entering my name below, I affirm I am the legal parent/guardian of the camp participant and that I am at least 18 years of age.
Your answer
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