Bsa Summer Camp Registration Form

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BSA 2016 Summer Camp Registration form
Your child basic information
Name____________________________________________________________
Birthdate ____/____/_____
Gender: M F
Home Phone number _______________________________________________________
Address______________________________________________________________________________________
Current School/Child Care_______________________________________________________________________
Father’s full name_________________________________ Father’s email address___________________________
Father’s cell phone________________________________ work phone____________________________________
Mother’s full name_________________________________Mother’s email address__________________________
Mother’s cell phone________________________________ work phone___________________________________
People permitted to pick up child:
Name: ____________________________phone:_________________________ __Relationship: ______________________________
Child’s medical insurance information and coverage
Physician: ______________________ Phone: ____________________________________________________________
Allergies(including drug reactions):_______________________________ Recent immunizations:____________________
Insurance Company Name_____________________________________ Member/Policy Number____________________
Policy Holder Name________________________________ Employer Name____________________________________
Please fill out the information below to help our teachers.
1.What do you want to your child gain from BSA day camp program?
__________________________________________________________________________
2.Is there anything special about your child that a new school should know?
________________________________________________________________
Please read the following waiver before you sign:
1. I read and agreed all tuition policies for day camp program.
2. My child has my permission to participate in the indoor/outdoor activities organized by Bright Seeds Academy. In case of medical
emergency when I cannot be reached through reasonable effort, I hereby give permission to the physician selected by the adult in
charge to secure proper treatment or to hospitalize. I further agree that I will not hold BSA, or any of its officers, directors, or instructors
responsible for any accident or injury arising out of my child's (or myself, in the case of adult student) participation in the program.
3. I understand that BSA students will take weekly field trips. I hereby give permission for my child to participate in these field trips by
using BSA transportation. I will also provide a car seat if needed. I will also help out for the field trip if needed.
4. I understand that BSA may take pictures of its students and their parents during school activities. I hereby give permission for BSA to
use the pictures of my child (or myself, in the case of adult student) for publication and school exhibitions.
5. This waiver is valid for all current and future courses I or my child may take, including but not limited to the courses indicated on this
form. I understand I am responsible for keeping our phone numbers, email addresses, and mailing address accurate and up-to-date with
BSA.
Parent/Guardian Signature:
Date
____________________________________________________
: _________________________
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