Today’s Date:

(MM/DD/YYYY)

CAMPUS DAY CAMP 2017
2901 Campus Road, Brooklyn, NY 11210 / (718) 421-7575

1. Child’s Information

Name:
Sex: M F
School:
Grade Entering:
Known Allergies:
Medical Conditions/Restrictions:
Birth Date:

(MM/DD/YYYY)

Age (by June 29):
Siblings/Age:

Special Needs:
 Yes
 No
If Yes Describe:

2. Parent/Guardian Information

Mother

Name:

Occupation:

Address:

Apt.

Zip:

Home Phone:

Cell Phone:

Carrier:

E-Mail:

Father

Name:

Occupation:

Address:

Apt.

Zip:

Home Phone:

Cell Phone:

Carrier:

E-Mail:

3. Child Pick-up and Emergency Contact Information

Please list persons with phone numbers whom you give permission to pick-up your child from the program.

Please note that we will not release children to anyone not on the list without prior authorization.

Children will not be released to anyone under the age of 16.

In the event of an emergency, these people will be contacted if a parent/guardian is unavailable.

Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:

4. Camp Fees (Please Circle)


Tuition

Grade Entering Full Summer
9:00am – 4:15pm
One Session
9:00am – 4:15pm
Adventurers
K-2nd Grade


Discoverers
3nd-4th Grade


Explorers
5th-10th Grade


Additions

Options Full Summer One Session
Bus One Way
AM
PM

AM
PM
Bus Both Ways

Early Drop 7:30am

Late Stay 6:00pm

Late Stay 7:00pm

Start Date:

(MM/DD/YYYY)

Deposit of 500.00 must be paid at time of registration.

Deposit will be applied to camp fee.

Camp must be paid for in full by no later than June 1, 2017.

Full summer is June 29-August 16. Single session is either June 29-July 21 or July 24-August 16

Total:   $

 


5. Parent/Guardian Consent

In case of an emergency injury or illness, I authorize the program to call the paramedics. As legal guardian of the above listed student, a minor, I authorize the program representative designee to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis, treatment, and/or hospital care to be rendered upon the advice of any licensed physician and/or dentist.

There will be no refund or pro-rating for absenteeism. It is our policy to charge 5.00 per quarter hour past closing time, which is 6:00 or 7:00 PM. If child is pulled out from program before end of summer no refund will be given.

Rules and regulations must be adhered to at all times.

Campus ASP Inc. reserves the right to suspend or expel a child from the program for disruptive or dangerous behavior.

Campus ASP Inc. and its employees are not responsible for personal items.

Campus ASP Inc. may at times use your child’s image on promotional items, both in print and online.

*We do not have a special needs program. Children may be accepted if they are able to be included within the group
and do not require one on one or any other additional services. We require a trial before admission of any child
with special needs.

I give consent for Campus ASP Inc. to pick up my child and attend trips using our full size school buses, mini buses, passenger vans, minivans/cars or by walking.
Yes

I give my consent for my child to attend Campus ASP Inc. and participate in its activities and trips.
Yes

I understand that my child will receive lunch and snack daily.
Yes

I have read and understand the above.

Parent/Legal Guardian Signature

 

 

(MM/DD/YYYY)


Camp Office: 718-421-7575

Copyright CAMPUS Inc. – 2017 ©