EmailMe Form - OLA Summer Camp Registration Form 2015

Today's Date *

MM / DD / YYYY

Family Information

Please complete all required fields.

Student's Last Name ONLY (Ex. Smith, Jones, Carter-Doe) *

Primary Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Parent/Guardian's Name *

First Last

Primary Phone *

### - ### - ####

Primary Phone

### - ### - ####

Email *

Parent/Guardian's Name

First Last

Email

Additional Address (if student lives at another address part-time)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Parent/Guardian's Name

First Last

Parent/Guardian's Name

First Last

Primary Phone

### - ### - ####

Primary Phone

### - ### - ####

Email

Student Information

Information can be collected for up to 4 students on this form.

Student's Name *

First Last

Grade for 2015-2016 School Year *

Weeks your student will attend the Morning Session 8 a.m.-1 p.m. ($100 per week, must be paid in advance) *

6/22/15-6/26/15

6/29/15-7/2/15 (Closed 7/3/2015)

7/6/15-7/10/15

7/13/15-7/17/15

7/20/15-7/24/15

7/27/15-7/31/15

All Weekly Sessions (5% Discount)

Drop in ($45 daily) paid at time of service

None

Failure to pay for your chosen weeks by 6/1/2015 could cause you to lose your reserved spot(s).

Weeks your student will attend the Extension Session 1 p.m.-5:30 p.m. ($80 per week, must be paid in advance) *

6/22/15-6/26/15

6/29/15-7/2/15 (Closed 7/3/2015)

7/6/15-7/10/15

7/13/15-7/17/15

7/20/15-7/24/15

7/27/15-7/31/15

All Weekly Sessions (5% Discount)

Drop in ($45 daily) paid at time of service

None

Failure to pay for your chosen weeks by 6/1/2015 could cause you to lose your reserved spot(s).

(2) Student's Name

First Last

Grade for 2015-2016 School Year

Weeks your student will attend the Morning Session 8 a.m.-1 p.m. ($100 per week, must be paid in advance)

6/22/15-6/26/15

6/29/15-7/2/15 (Closed 7/3/2015)

7/6/15-7/10/15

7/13/15-7/17/15

7/20/15-7/24/15

7/27/15-7/31/15

All Weekly Sessions (5% Discount)

Drop in ($45 daily) paid at time of service

None

Failure to pay for your chosen weeks by 6/1/2015 could cause you to lose your reserved spot(s).

Weeks your student will attend the Extension Session 1 p.m.-5:30 p.m. ($80 per week, must be paid in advance)

6/22/15-6/26/15

6/29/15-7/2/15 (Closed 7/3/2015)

7/6/15-7/10/15

7/13/15-7/17/15

7/20/15-7/24/15

7/27/15-7/31/15

All Weekly Sessions (5% Discount)

Drop in ($45 daily) paid at time of service

None

Failure to pay for your chosen weeks by 6/1/2015 could cause you to lose your reserved spot(s).

(3) Student's Name

First Last

Grade for 2015-2016 School Year

Weeks your student will attend the Morning Session 8 a.m.-1 p.m. ($100 per week, must be paid in advance)

6/22/15-6/26/15

6/29/15-7/2/15 (Closed 7/3/2015)

7/6/15-7/10/15

7/13/15-7/17/15

7/20/15-7/24/15

7/27/15-7/31/15

All Weekly Sessions (5% Discount)

Drop in ($45 daily) paid at time of service

None

Failure to pay for your chosen weeks by 6/1/2015 could cause you to lose your reserved spot(s).

Weeks your student will attend the Extension Session 1 p.m.-5:30 p.m. ($80 per week, must be paid in advance)

6/22/15-6/26/15

6/29/15-7/2/15 (Closed 7/3/2015)

7/6/15-7/10/15

7/13/15-7/17/15

7/20/15-7/24/15

7/27/15-7/31/15

All Weekly Sessions (5% Discount)

Drop in ($45 daily) paid at time of service

None

Failure to pay for your chosen weeks by 6/1/2015 could cause you to lose your reserved spot(s).

(4) Student's Name

First Last

Grade for 2015-2016 School Year

Weeks your student will attend the Morning Session 8 a.m.-1 p.m. ($100 per week, must be paid in advance)

6/22/15-6/26/15

6/29/15-7/2/15 (Closed 7/3/2015)

7/6/15-7/10/15

7/13/15-7/17/15

7/20/15-7/24/15

7/27/15-7/31/15

All Weekly Sessions (5% Discount)

Drop in ($45 daily) paid at time of service

None

Failure to pay for your chosen weeks by 6/1/2015 could cause you to lose your reserved spot(s).

Weeks your student will attend the Extension Session 1 p.m.-5:30 p.m. ($80 per week, must be paid in advance)

6/22/15-6/26/15

6/29/15-7/2/15 (Closed 7/3/2015)

7/6/15-7/10/15

7/13/15-7/17/15

7/20/15-7/24/15

7/27/15-7/31/15

All Weekly Sessions (5% Discount)

Drop in ($45 daily) paid at time of service

None

Failure to pay for your chosen weeks by 6/1/2015 could cause you to lose your reserved spot(s).

Emergency Contact Information

Name

First Last

Phone

### - ### - ####

Relationship to student(s)

Name

First Last

Phone

### - ### - ####

Relationship to student(s)

Name

First Last

Phone

### - ### - ####

Relationship to student(s)

Doctor's Name

First Last

Phone

### - ### - ####

Authorization of consent for treatment of a minor

In the event of a serious emergency, and none of the persons listed above can be contacted, I authorize OLA Extended Care officials to call my family physician, or if the situation demands, to transfer my child to the nearest hospital for emergency care. I consent to any X-Ray examination, anesthetic, medical or surgical diagnosis or treatment which is deemed advisable by, hand rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medicine Practice Act, whether such diagnosis or treatment is rendered at the physician’s office or at a certified hospital

Please choose one...

I hereby agree to bear all costs incurred as a result of the foregoing.

I do not chose to sign the above statement. In the event of an accident or emergency please: (Give instructions for care in the space provided below)

Alternate Care:

Pick Up List

Individuals listed are allowed to pick my student(s) up from Extension. Additions and alterations can be made to this list at anytime as long as a staff person is contacted by the student's legal gardian. ID is require for first time pick ups.

Name

First Last

Name

First Last

Name

First Last

Name

First Last

Name

First Last

Name

First Last

Name

First Last

Name

First Last

Name

First Last

Name

First Last

Name

First Last

Name

First Last

Name

First Last

Name

First Last

Name

First Last

Name

First Last

Important Note

By submitting this registration form, either in person or online, you are agreeing to all Extension rules, policies, standards and practices.
All of which are outlined in our handbook attached to this form. You can also have a hard copy printed out or emailed to you by sending a request to extension@olaparish.net

I have read the above statement and agree *

Agree

If you do not agree and wish to discuss this matter further please contact the Extension Director.