SAFARI CAMP @ SAFARI CHAMP
Summer Camp Registration Form
June 8th – August 21st
Parent 1:
Full Name: _________________ ph#:______________ Relation to the child: _________
Email: _________________________________ Address: ________________________________________
Parent 2:
Full Name: _________________ ph#:______________ Relation to the child: __________
Email: _________________________________ Address: ________________________________________
Child Information
Full Name: _________________ Sex: _______DOB: ______________ Allergies/special needs: Y/ N
If you have answered YES to the above, please explain your additional needs:
__________________________________________________________________________________________
__________________________________________________________________________________________
Name, Address & Phone number of the Emergency contact person.
__________________________________________________________________________________________
Name
Address/Phone #
Relation to the child
Name, Address & Phone number of the person the child can be released to.
__________________________________________________________________________________________
Name
Address/Phone #
Relation to the child
1
Immunization Records
Current Immunization Records must be presented upon your child's first visit unless held at the
following School or Pre-Kindergarten program,
__________________________________________________________________________________________
Name of Pre-kindergarten program or school
Address & Telephone number
____________________________________________________________________
PARENT SIGNATURE
DATE
Health Statement
My child has been examined by a licensed health professional and has stated that he/she is physically able to
take part in child care program OR my child has an appointment for an examination with a licensed health
professional OR medical diagnosis and treatment conflict with the tenets and practices of our recognized
religious organization.
Physician’s Name: _____________________ Phone Number: __________ Address: ____________________
In the event that I can not be reached, to make arrangements for emergency medical attention at the time
of illness or accidents, I authorize Safari Champ Drop-in Care center take my child to:
__________________________________________________________________________________________
Name of the Physician
Address & Phone #
__________________________________________________________________________________________
Name of the Hospital
Address & Phone #
I give consent for Safari Champ Drop-in Care to secure any and all necessary emergency medical care
for my child.
__________________________________________________________________________________________
PARENT SIGNATURE
DATE
RELEASE & NUTRITON STATEMENT
I hereby release Safari Champ Drop-in Care Center from medical liability due to any illness or injury
occurring during my child’s attendance at Safari Champ Drop-in Care Center and release its owners,
officers, agents, and employees from any liability. I will not hold Safari Champ Drop-in Care Center
financially responsible for the emergence care and/or transportation of my child.
___________________________________________________________________________
PARENT/GUARDIAN ADMISSION SIGNATURE
DATE
2
PLEASE CIRCLE YOUR SELCTION FROM THE FOLLOWING OPTIONS:
WEEK
8-12 THEME
PRICE
1-5 THEME
PRICE FULL
TIME
PRICE
JUNE 8TH -12TH
CAFÉ MONET
160
ANIMAL
160
335
JUNE 15TH – 19TH
MAD SCIENCE
(15KIDS REQUIRED)
200
SCIENCE
160
400
JUNE 22ND – 26TH
CERAMICS BY AMY
160
POTTERY
160
335
JUNE 29TH –
JULY 3RD
INDEPENDENCE
DAY
160
INDEPENDENCE DAY
160
335
JULY 6TH – 10TH
CAFÉ MONET
160
170
335
JULY 13TH – 17TH
GARDEN THEME
160
160
335
JULY 20TH – 24TH
160
160
335
JULY 27TH – 31ST
MUSICAL
INSTRUMENTS
ALL ABOUT FOOD
160
335
AUGUST 3RD – 7TH
CAFÉ MONET
160
170
350
AUGUST 10TH –14TH
SUPERHERO/
PRINCESS
160
LEGO LEARNING 101
(6 KIDS REQUIRED)
MS. SONI’S SUMMER
CAMP
MS. SONI’S SUMMER
CAMP
MS. SONI’S SUMMER
CAMP
LEGO LEARNING
(6 KIDS REQUIRED)
SUPERHERO/
PRINCESS
160
335
170
400
AUGUST 17TH – 21ST AROUND THE
WORLD
160
170
AROUND THE WORLD
1.
Email the complete form to [email protected] or submit it in person at Safari Champ (1400 East Old
Settlers Blvd # 200, Round Rock, TX 78665).
2.
The full payment must be made one week before the camp. Payments can be taken over the phone or in person.
Master Card, Visa and Discover are accepted.
3.
Lunch can be purchased at the camp. It is $4.5 a meal which includes an entree, a side and a drink. Parents can
provide lunch with the exception of peanut products. Snacks are included.
CALL 512-828-0000 FOR MORE INFORMATION.
__________________________________________________________________________________________
FOR OFFICE USE ONLY
CAMP OPTION:_____________
CAMP PRICE:_____________
BALNCE DUE:____________
TICKET NO.____________
3