Where children come first 2015 Summer Program Application: Child’s Name:______________________________________________________ Date of Birth: ______________________________________________________ Address:___________________________________________________________ Home Phone: ______________________________________________________ Mother’s Name: ____________________________________________________ Father’s Name: _____________________________________________________ Emergency Contact Number:___________________________________ Additional Contact and Number to call if parent (s) cannot be reached: __________________________________________________________________ Names of People Approved to Pick Up Child: ____________________________ Week(s) Attending: (Please circle week and days. If signing up for half days put a / through circle.) June 8-12 June 15-19 June 22-26 June 29-July 3 July 6-10 July 13-17 July 20-24 July 27-31 Aug 3-7 Aug 10-14 Need for After Camp Care: Yes No Please make checks payable to: Missoula Valley Montessori Payment is due the first day of each camp week. If payment has not been received, your child will not be able to attend. Thank you for your cooperation in this matter. Dismissal time is 3:00 or 5:15 for those in aftercare. A late fee of $5.00 in 5 minute increments will be charged for late arrival. I hereby authorize the staff of Missoula Valley Montessori to act for me according to their best judgment in any emergency requiring medical attention and hereby waive and release the camp from any and all liability for any injuries or illness that incurred while at Missoula Valley Montessori summer program. I have no knowledge of any physical impairment that would be affected by the above named camper's participation in the MVM camp programs. Parent signature required:____________________________________________________ Date:___________ Thank you!