Enrollment Form Official Use only: Entry Date_________ Exit Date_________ Preschool only ___ Childcare only ___ Preschool plus ___ Afterschool Only ___ Child’s name Last First Middle Street Address Parent/guardian name Home phone Street Address Parent/guardian name Home phone Street Address Nickname birthdate City Zip Cell phone Alternative phone City Zip Cell phone Alternative phone City Zip The following people may pick up my child. Name: Home: Relationship: Cell: Alternative: Name: Home: Relationship: Cell: Alternative: In the case of an emergency, I give my permission for any of the following individuals to be contacted and my child may be released to any of them. _________________________________________ Parent signature Name: Home: Relationship: Cell: Alternative: Name: Home: Relationship: Cell: Alternative: Consent to medical care and treatment of minor children I give permission that my child ___________________________, may be given first aid/emergency treatment by a qualified staff person at Acorn Learning Center. ______________________________________________ ______________________________________________ Parent/guardian signature Date Parent/guardian signature Date When I cannot be contacted or reached, I authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by a licensed physician, healthcare provider, hospital or aid car attendant when deemed necessary or advisable by the physician or aid car attendant to safeguard my child’s health. I waive my right of informed consent to such treatment. I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I certify under penalty of perjury under the laws of the State of Washington that this information is true and correct. ______________________________________________ ______________________________________________ Parent/guardian signature Has your child ever been in care before? If yes, where? Date Parent/guardian signature Date About your child Has there been any recent situation the child has been exposed to recently? (death, moving, divorce, etc) What is your normal method of discipline? What is your child’s temperament? Does your child have any food restrictions? Is your child potty trained? If yes, can your child be relied upon to indicate bathroom needs? Does your child have any siblings?(Please list names and ages) Does your child have any favorite books, toys, or outdoor activities? If yes, please list. What language is spoken at home? Does your child have any security objects such as a blanket or pacifier? Camp Selection Please check all that apply Animal* Art* Literacy Cooking July 6 - July 9 July 13 - July 16 July 20 - July 23 July 27 - July 30 Please specify which days you would like if choosing less than 4 days a week. 4__ 3___2___ 4__ 3___2___ 4__ 3___2___ 4__ 3___2___ Full day___ AM Half Day___PM Half Day___ Full day___ AM Half Day___PM Half Day___ Full day___ AM Half Day___PM Half Day___ Full day___ AM Half Day___PM Half Day___ Camp Costs Per Week 4 Days a week 3 days a week 2 days a week Full Day Half Day Full Day Half Day Full Day Half Day 6 weeks – 18 $200 $140 $160 $110 $115 $75 months 18 months – $180 $135 $150 $100 $110 $70 3 yrs 3 years and $170 $120 $135 $90 $95 $65 up Hourly $10 $9 $8 * Camp has a $10 field trip fee in addition to weekly camp costs. **Payments must be made two weeks prior to the camp start date. Checks, money orders, and cash are accepted as payment. Checks and money orders can be made out to TLC with your child’s name in the memo. A $15 non-refundable registration fee is due per camp at the time of registration. This will be placed towards your balance due at the time of payment. If payments are not received two weeks prior to your child’s camp start date, your child’s spot may be given away and you will not receive a refund of your registration fee.