You are here: Home > Summer Camp Registration Form
Summer Camp Registration Form
Child’s Name: Age:
Home Address: City: Zip:
Parents/Guardians: Cell #: Home #:
Work #: Ext.: Email Address:

Program (please choose one):

8:00am – 6:00pm (Full Day)
8:00am – 1:00pm (Half Day Program – Mornings)
1:00pm – 6:00pm (Half Day Program – Afternoons)

Weeks Attending (please check):

1 2 3 4 5 6 7 8

Release and Emergency Information:

Safety is a top priority therefore no child enrolled will be released from the program without parent/guardian consent and will only be released to the parent(s)/guardian(s) listed and the three individuals listed below (The names of individuals listed below must be at least 18 yrs & over with proper ID).

1. Name: Phone #: Relation:
2. Name: Phone #: Relation:
3. Name: Phone #: Relation:

Acknowledgement (please type name): Date:


Summer Camp Agreement

Please read the following information carefully. You must sign at the bottom where indicated that you understand and agree to all following.

Our summer camp programs are a place for all children to learn, have fun, and feel good about themselves in a safe environment.

Basic Information & Rules:

1. Registration and payments are due prior to start of each week’s camp.

2. Returned checks will incur an additional $25 bank fee.

3. Refunds are not issued or pro-rated for missed days.

4. Students participating in camp must be signed out everyday by parent, guardian or authorized adult.

5. Students registered in the camp program must be picked up by 6:00pm daily. A late pick-up fee of $15.00 will result for every 15 minutes or portion thereof past pick-up time.

6. Continual late pick-up will result in termination from program.

7. Participation in our summer camp is a privilege. Children must follow all program rules at all time. Disruptive or disrespectful behavior toward other students or our staff is reason for termination from the camp. We encourage you to discuss concerns about your child’s behavior with the on-site staff.

Please Note: If your child has permission to walk home as indicated on registration form, he or she must be signed out by program leader.

I have read and understand all of the information above. I agree to follow the guidelines and help my child understand and follow the rules.

Acknowledgement (please type name): Date:

Consent and Waiver of Liability:

In consideration of enrollment in the summer camp program, I hereby waive, release and hold harmless LA Enrichment Academy, the city, its Parks and Recreation Department, and their management, instructors, agents or representatives, to and from any and all claims for personal injury or property damage or loss.

Acknowledgement (please type name): Date:


Health Form
Child’s Name: Date of Birth:
Parents/Guardians: Phone # During Program Hours:

Name of two alternative relatives or friends who can be contacted in case a parent or guardian cannot be reached in the event of an emergency:

1. Name: Phone #: Relation:
2. Name: Phone #: Relation:

Name of Family Doctor: Phone #:

Does your child have medical insurance? (please choose one) Yes No

Name of Insurance Company:
Identification Number:
Policy Holder:

Health and Medical History:

1. Any Known Allergies? Yes No

If yes, please specify:
Medications used:

2. Any operations, serious injuries or chronic illness we should be aware of? Yes No

If yes, please specify:

3. Any known physical, mental, social difficulties or other information which may affect participation and/or for which special accommodations are needed? Yes No

If yes, please specify:

4. Any activity restrictions desired by parent/guardian or physician? Yes No

If yes, please specify:

To the best of my knowledge, I verify that the above information is complete and accurate. I understand that reasonable measures will be taken to safeguard the heath and safety of all participants and that I will be notified as soon as possible in case of an emergency. In the event I cannot be reached in an emergency, I herby authorize transportation to a medical facility and/or the calling of a physician at my expense to provide whatever emergency treatment is necessary.

Acknowledgement (please type name): Date:


Photographic Release
Name of Child:

My child will participate in activities conducted by LA Enrichment Academy, Inc.

I understand that my child may be photographed or videotaped during the course of participating in such activities, individually and/or as part of a group of children, and I consent to the taking of such photographs and/or videotapes.

I further consent to the use of such photographs and/or videotapes by LA Enrichment Academy, Inc., its employees, affiliates and contractors, in its advertising and promotional material, and agree that such photographs and/or videotapes may be used in printed literature, videotapes, video programs, and on the Internet at the sole discretion of LA Enrichment Academy, Inc. I waive all rights to inspect or approve the photographs and/or videotapes prior to their use.

Acknowledgement (please type name): Date:


Please enter the following code into the box below: