______ Morning

______  After

______  Both
 
Camp Eagle’s Nest Extended Care

Enrollment Form

 

 

Name                                                                 Date of Birth                  Grade                                               

 

Parent’s Name                                                                                       Teacher                                                         

 

Address                                                                                                 Home Phone                                                 

 

Child lives with                   Mother                        Father                        Both Parents       Other                                 

 

Mother works at                                                                         Wk Phone                    Cell Phone                             

 

Father works at                                                                          Wk Phone                    Cell Phone                             

 

Emergency Contact Name                                                          Phone                           Cell Phone                             

 

Email address___________________________________________________

In case of an accident or serious illness, and the school is unable to contact me, I authorize the school to call the physician indicated below and to follow his instructions.  If it is impossible to contact this physician, the school may take whatever arrangements deemed necessary.    

 

Parent’s signature                                                                                               Date                                                  

 

Physicians name                                                                                                  Phone                                                

 

Preferred Hospital                                                                                                                                                       

 

Medical conditions/medications                                                                                                                        

 

Student MAY be released to:

 

Name                                                                                                     Relationship                                       

 

Name                                                                                                     Relationship                                       

 

Student MAY NOT be released to:

Name                                                                                                     Relationship                                       

 

Name                                                                                                     Relationship                                       

 

 

I have read the Camp Eagle’s Nest Extended Care Rules and Guidelines and understand that if they are not met, my child may risk removal from the program.

 

I understand that there is a $25 registration fee per family for the 2008 – 2009 school year and that this fee is due prior to my child attending.   I also understand that I will be charged $1.00 per minute that my child is picked up after 6:00 P.M. and that the fee is due, in cash, to the employee that stays to supervise my child.