Summer camp registration
SUMMER WORKSHOP REGISTRATION
To register your child for summer workshops, please fill out this form and submit, along with full payment. Forms and payments should be sent to the address listed below. Checks should be made out to The Children’s Garden.
THE CHILDREN’S GARDEN
1324 South 1100 East
Salt Lake City, UT 84105
801-832-1100
2010 SUMMER WORKSHOPS
All workshops run Monday through Friday from. 9:00 am -12:00 pm with an optional lunch hour from 12:00pm to 1:00pm for an additional $5.00 fee.
Please Check the workshops you are registering for:
___ JUNE 21 – JULY 2 – MUSICAL THEATER WORKSHOP ($300.00)
___ JULY 5 -9 – MEET THE ARTISTS ($150.00)
___ JULY 19TH – 23 – HANDS ON ART ($150.00)
___ JULY 26 – 30 – YOU CAN DRAW ($150.00)
___ AUGUST 9 13 – ACADEMIC TUNE-UP ($150.00)
**$25.00 DISCOUNT FOR EACH SIBLING REGISTERED**
Child’s Full Name: _______________________________ Nickname: ____________________________
Birth Date: ____________________ Home Phone: ___________________ Email: __________________
Address: _____________________________City: ______________________ Zip Code: _____________
Child’s Full Name: _______________________________ Nickname: ____________________________
Birth Date: ____________________ Home Phone: ___________________ Email: __________________
Address: _____________________________City: ______________________ Zip Code: _____________
Child’s Full Name: _______________________________ Nickname: ____________________________
Birth Date: ____________________ Home Phone: ___________________ Email: __________________
Address: _____________________________City: ______________________ Zip Code: _____________
Mother’s Full Name: ___________________________________________________________________
Occupation: _____________________________Name of Employer: _____________________________
Work Phone _____________________ Pager or Cellular Phone: ________________________________
Business Address: ______________________________Work Hours: _____________________________
Father’s Full Name: ___________________________________________________________________
Occupation: ____________________________ Name of Employer: _____________________________
Work Phone _____________________ Pager or Cellular Phone: ________________________________
Business Address: _______________________________Work Hours: ____________________________
EMERGENCY CONTACT INFORMATION
Emergency Contacts (Within a 20-mile radius of preschool other than parent or guardian)
Primary Emergency Contact (other than parents or guardian) ____________________________________________________________________________ Home Phone: _________________________ Work Phone: ____________________________________
Relationship to Child: __________________________________________________________________
Address: ___________________________________________________________________________
Secondary Emergency Contact (other than parents or guardian) ___________________________________
Home Phone: _________________________ Work Phone: ____________________________________
Relationship to Child: _________________________________________________________________
Address: ____________________________________________________________
Person(s) authorized to pick up my child: (Besides parents, guardians, or emergency contacts) __________________________________________________________________ Person(s) NOT authorized to pick up my child: (Besides parents, guardians, or emergency contacts) ______________________________________________________________________
Emergency Release Consent to Emergency First Aid & Transportation
I hereby give permission that my child may be given emergency treatment by a staff member at THE CHILDREN’S GARDEN. I also give permission for my child to be transported by car or ambulance to an emergency room for treatment, and agree to hold THE CHILDREN’S GARDEN and its employees harmless.
Signature: ______________________________________________Date: _________________________
Consent to Medical Care and Treatment
In the event that I cannot be contacted immediately, medical or surgical treatment can be administered to my child in the case of an accident or emergency, as prescribed by a treating physician, and hold THE CHILDREN’S GARDEN and its employees harmless. I agree that neither I, nor my child will bring any claims of any kind against THE CHILDREN’S GARDEN and its employees as a result of any injuries, expenses or damages that I or my child may suffer in any way related to the use of our facilities, toys, other children, teachers, whether such claims are known or unknown or arise in the future.
Signature: ______________________________________________Date: _________________________
Emergency Medical Information
Child’s Physician: ________________________________ Phone: _______________________________ Preferred Hospital: ________________________________Phone: _______________________________ Primary Insurance_____________________________ Group #: _____________________________ Regular Medications: ___________________________________________________________________
Blood Type: _______________________________Allergies to medicines: _________________________
Food Allergies: ________________________________________________________________________
Any other Allergies: ____________________________________________________________________ Any special health conditions: ____________________________________________________________
MEDICAL INFORMATION
PAST MEDICAL HISTORY OF THE CHILD:
- Any hospitalizations or surgeries? ______________________________________________________
- Any serious injuries or medical attention? ________________________________________________
- Are immunizations up to date? ________________________________________________________
CURRENT MEDICAL HISTORY OF THE CHILD:
- Medications: ______________________________________________________________________
- Any Allergies to medications? _________________________________________________________
- Food Allergies? ____________________________________________________________________
RECENT/CURENT CONDITIONS (check all that apply):
Recurrent earaches or headaches?
Recurrent stomach Aches
Eye problems
Hearing problems
Urinary Problems
Allergies
Other?
_____________________________________________________________________
Please tell us of any special considerations your child may require ___________________________________________________________________________
Photograph Consent
From time to time photographs or videotapes may be taken of the children involved in preschool activities. I hereby give my permission for THE CHILDREN’S GARDEN to photograph my child _________________________________________________.
I understand these materials may be used for printed or virtual promotion of THE CHILDREN’S GARDEN.
Signature: _____________________________________Date: __________________________________