KUM SUNG SUMMER DAY CAMP ENROLLMENT FORM

 

CHILD INFORMATION:

 

Name                                                                                                                                                                          (First)                                                               (Last)

Gender: Male             or Female                                  Birth Date                      Age:           

 

CUSTODIAL PARENT OR GUARDIAN INFORMATION:

Name                                                                                                                                                                                     

                                        (First)                                                                                      (Last)

Address                                                                                                                                                                                

City/State/Zip                                                                                                                                                                      

Home#                                                   Work#                                                    Cell#                                                      

SECOND PARENT INFORMATION:

Name                                                                                                                                                                                     

                                (First)                                                                                      (Last)

Address (if different from above)                                                                                                                                     

City/State/Zip                                                                                                                                                                      

Home#                                                   Work#                                                    Cell#                                                      

AUTHORIZED PICK UP INFO:

  1. Name                                                                      Relationship                                          Phone#                 
  2. Name                                                                      Relationship                                          Phone#                 
  3. Name                                                                      Relationship                                          Phone#                 

 

IF NOT AVAILABLE IN AN EMERGENCY, NOTIFY,   Name                                                                  

Relationship                                                                          Phone #                                                                                

Address                                                                                                                                                                                

 

 

PAYMENT INFORMATION:            ** ALL TRIPS ARE EXTRA **

 

Enrolled Sessions (Circle weeks applicable):  ALL 11 WEEKS or              

6/16---6/23---6/30---7/7---7/14---7/21---7/28---8/4---8/11---8/18---8/25

Enrolled Days (Circle the day(s) applicable): (NO MAKE UP DAYS AVAILABLE)

ALL---Monday---Tuesday---Wednesday---Thursday---Friday

(Price for 4 days are same as for the whole week.)

                                                Costs                      (excludes field trip fees)

1st Child                  Two Days $130     Three Days $175                  Four/Five Days $209

2nd Child Two Days $120     Three Days $165                  Four/Five Days $199

 

Registration Fee $50.00     Deposit                                

Total Payment Amount (calculated as follows)

                ____ X                     =                                             + REG. FEE $50.00               =                                            

# of Weeks       $ per Days                  Total                                                                                       Grand Total

 

PAYMENT PLAN

     Date                         Amount                                     Date                        Amount

1.                                                                                             5.                                                                            

2.                                                                                             6.                                                                            

3.                                                                                             7.                                                                            

4.                                                                                             8.                                                                            

 

Credit Card #                                                                                                       Expiration Date                   

 

Authorized Signature:X                                                                                   Date                                                       

 

No Refund or Credit will be given for missing days without an advance written notice unless accompanied by a doctor’s note.  No Refund or Credit will be given for July 4th.

 

 

 

MEDICAL INFORMATION:

Doctor’s Name                                                     Dentist Name                                                                       

Phone #                                                                 Phone #                                                                

 

INSURANCE INFORMATION:

Insurance Company Name                                                                                                

Address                                                                                                                                                                

Phone #                                                                 Policy #                                                                 

 

ALLERGIES         List all known.  Describe reaction and management of the reaction.

Medication allergies (list)

                                                                                                                                                                                               

                                                                                                                                                                                               

Food Allergies (list)

                                                                                                                                                                                               

                                                                                                                                                                                               

Other Allergies (list) – include insect stings, hay fever, asthma, animal dander, etc.

                                                                                                                                                                                               

                                                                                                                                                                                               

 

MEDICATIONS BEING TAKEN:     WE DO NOT ADMINISTER ANY MEDICATION!

Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely.  Attach additional pages for more medications.

Med #1                                       Reason for taking                      Med #2                                   Reason for taking

                                                                                                                                                                                                               

 

RESTRICTIONS (The following restrictions apply to this individual)

                                                                                                                                                                                               

                                                                                                                                                                                               

 

EXISTING MEDICAL CONDITIONS

Use this space to provide any additional information about the participant’s behavior and physical, emotional, or mental health about which the program should be aware.

                                                                                                                                                                                               

                                                                                                                                                                                               

 

IMMUNIZATION (Please give date for last immunization for)

Date                         Vaccine                    Date                         Vaccine

                                DTP                                                        Measles (hard or red measles or rubeola)

                                Rubella                                                     TD (tetanus/diphtheria)

                                Tetanus                                                    Haemophilus influenza B

                                Polio                                                        Varicella Zoster

                                Hepatitis B

 

Which of the following has the participant had?

                Measles    Chicken Pox           German Measles        Mumps                     Hepatitis

 

Permission to Provide Necessary Treatment or Emergency Care:

I hereby give permission to the medical personnel selected by the program director to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child.  In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the program director to secure and administer treatment, including hospitalization, for the person named above.  This completed form may be photocopied for trips out of facility.

 

Kum Sung reserves the right to dismiss a child from camp whose special needs we are not able to meet or whose conduct is not in the best interests of the program.

Kum Sung is granted the right to use any and all pictures taken of afterschool activities in their publication of materials for promotion of Kum Sung activities.

Believing my child is qualified for afterschool program, I give permission for my child to take part in all activities.  I agree to place him/her in care of the afterschool program, subject to all its rules and regulations.  I understand the nature and purpose of the camp activities and I am aware that any strenuous physical activity involves risks.  Accordingly, I release, discharge, absolve, and hold harmless the Kum Sung Martial Arts and K.S. Fitness Center, their agents and employees, and instructors, from any and all liability arising out of any accident, injury, or loss sustained by my child as a result of activities at or present in the facility except for accidents, injuries or losses sustained as a result of gross negligence and willful misconduct of the facility.  I agree to waive any and all claims against persons connected with Kum Sung Martial Arts and KS Fitness Center. 

I declare to the best of my knowledge my answers are true, correct and complete.

Parent Signature:X                                                                            Date: