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T.L.C. SUMMER CAMP 2011 Camp Registration Form

Camper Information:

First Name:

Last Name:

Date of Birth:

Gender:

Grade level (for upcoming school year):

Mailing Address:

City:

State:

Zip:

Parent/Caregiver 1:

Home Phone #

Work/Cell:

Email:

Parent/Caregiver 2:

Home Phone #

Work/Cell:

Email:

How did you hear about us?

What are your child's strengths?

What skills would you like us to work on?

Does your child have an IEP?

My child receives the following services (check all that apply):

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MEDICAL INFORMATION:

Does your child have any injuries, restrictions

for physical activities, or dietary restrictions, etc.?

(If yes, please explain)

Does your child have any allergies to

food, medications, etc.?

(If yes, please explain)

Primary Care Physician:

Phone #

EMERGENCY CONTACT (Please list an emergency contact person other than this camper's parents/caregivers. Parents/caregivers will be contacted first unless otherwise indicated)

Name:

Phone #

Camp Medical Authorization and Liability Release

As parent or legal guardian of this child, I hereby give my permission to the Staff at TLC Summer Camp to pursue medical or surgical care for my above named child should the need arise. The permission may include transportation to and from a medical facility by a Faculty or Staff member or calling for an emergency medical service ambulance. An attempt will be made to contact the parents before any action is taken. I agree to accept any expenses incurred.

Electronic Signature (please type full name):

PHOTO CONSENT

I give consent to Total Language Connections, Inc. to take photos of my child, and use them for the following purposes: