Summer 2013 Application Checklist

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Summer 2013 Application Checklist"

Transcription

1 Summer 2013 Application Checklist \ Forms Camp Application Payment Form Authorization for Medication /Treatment Reminder Complete registration form Checks should be made payable to Camp Nova. We also accept Cash, Visa, Master Card, and American Express. No Refunds. Must be signed by both parents and physician. For all campers. Non University School Students: Extra Medical Forms Non University School Students must submit the following two forms: DH/HRS 3040 form and a DH/HRS 680 form which can be requested from your child s physician. Visit : Parent FAQs Orientation Date: June 8 th, 2013 Time: 10am-12pm Location: Epstein Center

2 Camper 1: Name: M F D.O.B: Grade Entering in the fall: School: Camper 2: Name: M F D.O.B: Grade Entering in the fall: School: PARENT/GUARDIAN CONTACT INFORMATION Mother/Guardian/Co-Parent Father/Guardian/Co-Parent Name: Name: Address: Address: City: State: Zip Code: City: State: Zip Code: Home #: Work #: Home #: Work #: Cell #: Cell #: Address: Address: AUTHORIZATION TO RELEASE: Other than parent(s), please list additional people who are authorized to pick up the camper. EMERGENCY CONTACTS RELEASE OF LIABILITY: As a parent or legal guardian of the above camper(s), I/we agree for the noted camper(s) to attend Camp Nova: Summer Camp and all off-campus activities. I/we give permission for camper(s) to engage in all prescribed activities as noted. I/we authorize and give consent to any licensed health professional to perform upon or administer to camper(s) any reasonable, necessary medical treatment. Initial: I/we authorize the use of my camper(s) photograph(s) in camp publications, web sites, and or/or advertisements. I/we hereby release Nova Southeastern University, Inc., its trustees, officers, agents, and employees, the University School, its officers, employees, agents and instructors from any and all liability for any injury, damage, claim, demand, action, loss, liability, cost and expense (including, without limitation, reasonable attorney s fees) of any nature that I/we may at any time have or incur, while taking part in a University School/ program. NON-REFUND POLICY: A NON REFUNDABLE DEPOSIT OF $100 PER CHILD/PER SESSION IS REQUIRED FOR YOUR CAMPER TO BE REGISTERED. THIS WILL BE DEDUCTED FROM THE TUITION FOR EACH SESSION. Initial: I understand the deposit enclosed will be applied toward one session of each camper s basic fee. I agree to pay the balance on or before April 5, I am aware this deposit is non-refundable and will be forfeited if my child does not attend. There is no-refund for late arrival or early departure for a camper dismissed for disciplinary action or for emergency weather situations. If payment procedures are not followed, the person responsible for payment will be sent to collections. Refunds are not issued if a child is dismissed due to disciplinary action based on his/her behavior or misconduct. Only in the case of an extreme medical emergency will this policy be reviewed by University School. Refunds will also not be issued in the event that the National Hurricane Center broadcasts a hurricane/tropical storm warning for our area. In such a case, will cancel its program for the duration of the inclement weather. We reserve the right to cancel programs if there is insufficient enrollment. Parent/Guardian Signature: Date:

3 (One form per camper) Camper 1: Name Date of Birth Age Female Male Grade in fall Shirt Size Child S M L Adult S M L Jr. (K-1 st Grade Only) Teen Travel Camp (8 th -10 th Grade Only) C.I.T. (9 th -12th Grade Only) Cheer Camp (2 nd -8 th Grade Only) Session 1: 6/10/13-6/21/13 Session 1: 6/10/13-6/21/13 Session 1: 6/10/13-6/21/13 Session 1: 6/10/13-6/21/13 Session 2: 6/24/13-7/5/13 Session 2: 6/24/13-7/5/13 Session 2: 6/24/13-7/5/13 Session 2: 6/24/13-7/5/13 Session 3: 7/8/13-7/19/13 Session 3: 7/8/13-7/19/13 Session 3: 7/8/13-7/19/13 Session 3: 7/8/13-7/19/13 Session 4: 7/22/13-8/2/13 Session 4: 7/22/13-8/2/13 Session 4: 7/22/13-8/2/13 Session 4: 7/22/13-8/2/13 Volleyball Camp Basketball Camp Jr. Lifeguard (2 nd -8 th Grade Only) (2 nd -6 th Grade Only) (4 th -8th Grade Only) Week 7:7/22/13-7/26/13 Week 1: 6/10/13-6/14/13 Session 2: 6/24/13-7/5/13 Week 2: 6/17/13-6/21/13 CORE CAMPS (Grades 2-8 Only) Full Day Camps Campers will spend each full day participating in the activity as well as participate in swimming, fieldtrips and camp-wide activities. SESSION 1: 6/10/13-6/21/13 SESSION 2: 6/24/13-7/5/13 SESSION 3: 7/8/13-7/19/13 SESSION 4: 7/22/13-8/2/13 AM PM BEFORE CARE (7:30-8:30 AM) AND/OR AFTERCARE (3:30-5:30 PM) AM PM AM PM AM PM RELEASE: THIS STATEMENT MUST BE SIGNED FOR ATTENDANCE. The person herein described has permission to engage in all prescribed activities as noted. Initial: MEDICAL INFORMATION Your camper s health and safety is very important to all of us at. Please be assured that we will share any and all medical/allergy information with your campers counselors, including all camp vendors (i.e. Magic Program) who interact with your children. Please let us know if there are any additional concerns that the staff should be aware of?

4 (One form per camper) Camper 2: Name Date of Birth Age Female Male Grade in fall Shirt Size Child S M L Adult S M L Jr. (K-1 st Grade Only) Teen Travel Camp (8 th -10 th Grade Only) C.I.T. (9th-12 th Grade Only) Cheer Camp (2 nd -8 th Grade Only) Session 1: 6/10/13-6/21/13 Session 1: 6/10/13-6/21/13 Session 1: 6/10/13-6/21/13 Session 1: 6/10/13-6/21/13 Session 2: 6/24/13-7/5/13 Session 2: 6/24/13-7/5/13 Session 2: 6/24/13-7/5/13 Session 2: 6/24/13-7/5/13 Session 3: 7/8/13-7/19/13 Session 3: 7/8/13-7/19/13 Session 3: 7/8/13-7/19/13 Session 3: 7/8/13-7/19/13 Session 4: 7/22/13-8/2/13 Session 4: 7/22/13-8/2/13 Session 4: 7/22/13-8/2/13 Session 4: 7/22/13-8/2/13 Volleyball Camp Basketball Camp Jr. Lifeguard (2 nd -8 th Grade Only) (2 nd -6 th Grade Only) (4 th -8 th Grade Only) Week 7:7/22/13-7/26/13 Session 1: 6/10/13-6/14/13 Session 2: 6/24/13-7/5/13 Session 2: 6/17/13-6/21/13 CORE CAMPS (Grades 2-8 Only) Full Day Camps Campers will spend each full day participating in the activity as well as participate in swimming, fieldtrips and camp-wide activities. SESSION 1: 6/10/13-6/21/13 SESSION 2: 6/24/13-7/5/13 SESSION 3: 7/8/13-7/19/13 SESSION 4: 7/22/13-8/2/13 BEFORE CARE (7:30-8:30 AM) AND/OR AFTERCARE (3:30-5:30 PM) AM PM AM PM AM PM AM PM RELEASE: THIS STATEMENT MUST BE SIGNED FOR ATTENDANCE. The person herein described has permission to engage in all prescribed activities as noted. Initial: MEDICAL INFORMATION Your camper s health and safety is very important to all of us at. Please be assured that we will share any and all medical/allergy information with your campers counselors, including all camp vendors (i.e. Magic Program) who interact with your children. Please let us know if there are any additional concerns that the staff should be aware of?

5 Payment Form DEPOSITS AND PAYMENT A non-refundable deposit of $ per camper, per session must accompany the application for registration to be complete. This deposit will be applied to the camp fees. The person responsible for payment must sign the application form. has a no-refund policy. All accounts must be paid in full by May 3 th, 2013 Upon receipt of the application, a confirmation will be sent that includes the balance due and the dates by which payment must be received. If you do not receive a confirmation within two weeks of sending in the application, please call the camp office at (954) Camper 1 Name: Camper 2 Name: Camper 1: 2 Weeks 4 Weeks 6 Weeks 8 Weeks $ $1, $1, $2, Camper 2: 2 Weeks 4 Weeks 6 Weeks 8 Weeks $ $1, $1, $2, Teen Travel 2 Weeks 4 Weeks 6 Weeks 8 Weeks Teen Travel 2 Weeks 4 Weeks 6 Weeks 8 Weeks $ $1, $1, $2, BASKETBALL CAMP Week 1 Week 2 $ $ Before Care $31.25 $31.25 $32.50 $32.50 After Care $62.50 $62.50 CIT Weeks 1-4 Weeks 5-8 $ $ $ $1, $1, $2, BASKETBALL CAMP Week 1 Week 2 $ $ Before Care $31.25 $31.25 $32.50 $32.50 $62.50 $62.50 CIT Weeks 1-4 Weeks 5-8 $ $400.00

6 Jr. Lifeguard 2 Weeks $ Before Care $62.50 $65.00 After Care Cheer Camp: $ Weeks 4 Weeks 6 Weeks 8 Weeks $ $ $1, $1, Jr. Lifeguard Cheer Camp: 2 Weeks 4 Weeks 6 Weeks 8 Weeks $ $ $1, $1, Weeks $ Before Care $62.50 $65.00 After Care $ Additional T-shirt order: $15.00 each: Tote bag: $18.00 each: Total: $ Additional T-shirt order: $15.00 each: Tote bag: $18.00 each: Total: $ Pay By: Check Cash MasterCard Visa American Express -ALL DEPOSITS ARE NON-REFUNDABLE- Make check payable to: Credit card type: VISA MASTERCARD AMEX Cardholder s name: Signature: Credit card #: Billing Address: Billing Zip Code: Expiration Date: / / Amount: $ Registration forms can be faxed or submitted to the Camp Office located in the University Lower School

7 Authorization for Medication/Treatment 2013 This form MUST BE SIGNED BY THE CAMPER S PARENT/GUARDIAN AND PHYSICIAN. No student will be permitted to participate in University School s Summer Programs without returning this form with BOTH signatures. The purpose of this form is to allow University School s nurse and directed staff to carry out minor medical treatment (such as band-aids) when needed. Even if you do not want the program to administer any type of aid to your camper this form must be turned in. If physician s signature is not present we CANNOT give out any authorized medication to camper if needed! Any medication sent from home, including OTC and prescription, must be in the original container. Only medications/treatments authorized by a physician may be administered by Summer Program personnel. It is your responsibility to notify Summer Program personnel when there is a change in medication/treatment regimen. Student Name: Allergies: Date of Birth: Age: Grade: OTC (Over-the-counter) STANDING ORDERS MEDIATION DOSAGE FREQUENCY INDICATION FOR USE Acetaminophen Ibuprofen Benadryl Tums Caladryl Lotion Neosporin Chloraseptic Spray OTHER MEDICATIONS MEDICATION DOSAGE FREQUENCY INDICATION FOR USE TREATMENTS DURING CAMP HOURS (i.e.; nebulizer, blood glucose checks, etc): ADDITIONAL FORMS NEEDED! IMPORTANT: Broward County Dept. of Health requires us to have a physician signed copy of current (within one year of the first day of Summer Programs) Certificate of Good health, known as the DH/HRS 3040 (YELLOW) AND DH/HRS 680 (BLUE) FORMS. ALL NON UNIVERSITY SCHOOL STUDENTS MUST SUBMIT ORIGINAL COPIES OF THE BLUE AND YELLOW FORMS IN ADDITION TO THIS AUTHORIZATION FOR MEDICATION/TREATMENT FORM. A sample of the blue and yellow sheets can be found in this packet. / / Physician s Name (Please print) Physician s Signature and Stamp Date Physician s Phone: ( ) Physician s Fax: ( ) I grant the nurse, and/or primary designee the permission to assist or perform the administration of each medication or treatment/procedure to/for my child during Summer Programs including when he/she is away from the property on scheduled field trips. / / ( ) Parent/Guardian Name (Please print) Signature of Parent/Guardian Date Cell Phone Number Home Phone: ( ) Work Phone: ( )

Summer 2016 Registration Checklist

Summer 2016 Registration Checklist Summer 2016 Registration Checklist Forms Camp Registration 2016 Payment Form Reminder Complete registration form Checks should be made payable to Camp Nova. We also accept Cash, Visa, Master Card, and

More information

2016 FLORISSANT SUMMER PLAYGROUND INFORMATION AND POLICIES

2016 FLORISSANT SUMMER PLAYGROUND INFORMATION AND POLICIES 2016 FLORISSANT SUMMER PLAYGROUND INFORMATION AND POLICIES CAMP LOCATIONS CAMP DATES/TIMES June 6 July 15, 2016 James J. Eagan Center (300) 9:00am 3:00pm Koch Park (320) No camp July 4th All Prices Subject

More information

Registration Form Penn State Weather Camp June 14 19, 2015 Penn State Advanced Weather Camp June 21 26, 2015

Registration Form Penn State Weather Camp June 14 19, 2015 Penn State Advanced Weather Camp June 21 26, 2015 Registration Form Penn State Weather Camp June 14 19, 2015 Penn State Advanced Weather Camp June 21 26, 2015 TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN. Date of Program Please print in ink or type, and

More information

Compass Road to College Summer Tour Application

Compass Road to College Summer Tour Application Compass Road to College Summer Tour Application Student Information Name: Email Address: Sex: F M Birth Date: Primary Language Spoken at Home: English Spanish Other: Current School: School You ll be Attending

More information

Important Information Please keep this page for your records

Important Information Please keep this page for your records Camp Horizon Important Information Please keep this page for your records 1. Complete the enclosed application and the scholarship form thoroughly. Mail them immediately to the camp address listed below.

More information

Winter Camp 2015 Church Registration Instructions and Policies

Winter Camp 2015 Church Registration Instructions and Policies Winter Camp 2015 Church Registration Instructions and Policies Registration Instructions: 1) Choose your weekend(s). Prayerfully consider which available weekend is the best for your church. Bring your

More information

Youth Programs Registration Form Summer of Service (SOS) 2015

Youth Programs Registration Form Summer of Service (SOS) 2015 Youth Programs Registration Form Summer of Service (SOS) 2015 Participant s Information PHONE GENDER: FEMALE OF BIRTH SCHOOL GRADE IN FALL 2015 MALE ETHNIC BACKGROUND AFRICAN ASIAN INDIAN LATINO NATIVE

More information

THE CENTER FOR GLOBAL EDUCATION & CITIZENSHIP

THE CENTER FOR GLOBAL EDUCATION & CITIZENSHIP THE CENTER FOR GLOBAL EDUCATION & CITIZENSHIP 2011 SUMMER FASHION PROGRAM STUDENT APPLICATION CHECKLIST To apply for the Summer Fashion Program, please submit the required documents to The Center for Global

More information

2015 Nature Explorers Registration Form (Rising 1st to 3rd graders)

2015 Nature Explorers Registration Form (Rising 1st to 3rd graders) Information 2015 Nature Explorers Registration Form (Rising 1st to 3rd graders) Camper Name: DOB: Parent/Guardian Name(s): Address: City: State: Zip: Home Cell Work Email: *If emergency contact is different

More information

2016 Bowdoin Summer Art Camp Registration

2016 Bowdoin Summer Art Camp Registration 2016 Bowdoin Summer Art Camp Registration Hours and Location Bowdoin Summer Art Camp will run for four weeks from June 27 th through July 22 th. The times and length of each session vary. Please refer

More information

2016 CAMP DISCOVERY REGISTRATION

2016 CAMP DISCOVERY REGISTRATION 2016 CAMP DISCOVERY REGISTRATION We must have 2 weeks written notice prior to a child canceling camp or you will be charged the full amount Please print all information clearly (blue or black pen only)

More information

Youth Camp Civic Center

Youth Camp Civic Center Youth Camp Civic Center Household ID # Please circle the session(s) that your child(ren) will attend Session One June 8- June 12 Session Two June 15 June 19 Session Three June 22 June 26 Session Four June

More information

2016 Summer Art Camp Scholarship Application Parental Consent Form

2016 Summer Art Camp Scholarship Application Parental Consent Form QUINLAN VISUAL ARTS CENTER April 17, 2016 Georgia Schools Attn.: Art Instructors, Principals Re: 2016 Summer Art Camp Scholarship Application Parental Consent Form Dear School Art Instructor and School

More information

2016 Summer Camp Registration Form

2016 Summer Camp Registration Form 2016 Summer Camp Registration Form 1 of 6 2016 Summer Camp Registration Form All forms can be found online: http://go.dtcc.edu/swcamps q New Camper q Returning Camper Office Use Only: Identification Number

More information

Register Online at: www.pinecrest.edu/pcdc. 1501 NE 62 nd Street Fort Lauderdale, FL 33334. Phone: 954.492.4137. E-mail: daycamp@pinecrest.

Register Online at: www.pinecrest.edu/pcdc. 1501 NE 62 nd Street Fort Lauderdale, FL 33334. Phone: 954.492.4137. E-mail: daycamp@pinecrest. Register Online at: www.pinecrest.edu/pcdc 1501 NE 62 nd Street Fort Lauderdale, FL 33334 Phone: 954.492.4137 E-mail: daycamp@pinecrest.edu Pine Crest Day Camp 1501 NE 62 nd Street, Fort Lauderdale, FL

More information

Glenburnie Summer Camp 2015 Registration Please read and sign where necessary.

Glenburnie Summer Camp 2015 Registration Please read and sign where necessary. Glenburnie Summer Camp 2015 Registration Please read and sign where necessary. Registration Information: Please complete one form per child by providing all the necessary information, checking off your

More information

Dear Corner Stone Charter Parent:

Dear Corner Stone Charter Parent: Dear Corner Stone Charter Parent: Welcome to Boll Family YMCA s School Age Child Care (SACC) program. We are looking forward to sharing the next 11 months with your child before and after school. Attached

More information

Mathematical Logic: From Puzzles to Infinities FOR ADVANCED MIDDLE AND HIGH SCHOOL STUDENTS Day Enrichment Program Summer 2014

Mathematical Logic: From Puzzles to Infinities FOR ADVANCED MIDDLE AND HIGH SCHOOL STUDENTS Day Enrichment Program Summer 2014 Mathematical Logic: From Puzzles to Infinities FOR ADVANCED MIDDLE AND HIGH SCHOOL STUDENTS Day Enrichment Program This two week day enrichment program on the campus of Rensselaer Polytechnic Institute

More information

CHALLENGER WORLD TOURS (CWT)

CHALLENGER WORLD TOURS (CWT) CHALLENGER WORLD TOURS (CWT) TRAVELER REGISTRATION DOCUMENT & TERMS AND CONDITIONS Mail, Fax or Scan/Email To: Challenger World Tours Attn: Gareth Hughes 8263 Flint, Lenexa, KS 66214 USA Phone: 800 878

More information

First Name: Last Name: Home Address: City: State: Zip: Gender: Male Female Date of Birth / / / Age: Grade in Sept. 2016:

First Name: Last Name: Home Address: City: State: Zip: Gender: Male Female Date of Birth / / / Age: Grade in Sept. 2016: Please complete the entire form. Incomplete forms will not be processed. Please include a 50 NONREFUNDABLE DEPOSIT. Please complete a separate form for each camper. Please Print CAMPER INFORMATION For

More information

Camper Information Form

Camper Information Form Camper Information Form NO CAMP HELD ON JULY 4, 2016 Please Mark Dates Attending: Session 1: June 27 July 8 Session 2: July 11 July 22 Session 3: July 25 August 5 ALL 3 SESSIONS Personal Information Name

More information

Al Wooten Jr. Heritage Center. Summer Fun Camp REGISTRATION FORM. Student 1: When will Student 1 attend? Mon-Fri, 8am-6pm / Other schedule

Al Wooten Jr. Heritage Center. Summer Fun Camp REGISTRATION FORM. Student 1: When will Student 1 attend? Mon-Fri, 8am-6pm / Other schedule REGISTRATION FORM Student 1: When will Student 1 attend? Mon-Fri, 8am-6pm / Other schedule Student 2: When will Student 2 attend? Mon-Fri, 8am-6pm / Other schedule Scholarship requested for low-income

More information

Schooner SULTANA Middle School 5-Day Trips 2016

Schooner SULTANA Middle School 5-Day Trips 2016 Updated Nov., 2015 Summer Program Forms Packet for Schooner SULTANA Middle School 5-Day Trips 2016 Forms for Your Reference Pick-Up & Drop-Off Information-page 2 Packing List - page 3 Forms That Must Be

More information

Application Summer Study - Pre-College New York Summer Study 2016

Application Summer Study - Pre-College New York Summer Study 2016 Application Summer Study - Pre-College New York Summer Study 2016 First Name Birth Date (Month/Day/Year) Address Last Name Male Female City State Zip/Country code Country Home Tel. E-mail Current School

More information

CAMP 2015 Tuesday 6/23 Friday 8/14 REGULAR CAMP RATES

CAMP 2015 Tuesday 6/23 Friday 8/14 REGULAR CAMP RATES CAMP 2015 Tuesday 6/23 Friday 8/14 REGULAR CAMP RATES Session Rates 8 Weeks and 4 Weeks 20 Months 5 Years (5 by December 2015) Campers Entering 1st grade - 3rd Grade in fall Session # s - Dates Full Day/Half

More information

Big House 2015. Cost for the Trip $125 if turned in by March 29th $150 if turned in by April 26th $175 if still space in the camp after April 26th

Big House 2015. Cost for the Trip $125 if turned in by March 29th $150 if turned in by April 26th $175 if still space in the camp after April 26th Cost for the Trip $125 if turned in by March 29th $150 if turned in by April 26th $175 if still space in the camp after April 26th Big House 2015 June 11-14 Bellville, TX Big House is a summer mission

More information

2016 SUMMER DAY CAMP REGISTRATION YMCA OF BEAUFORT County SITE LOCATION

2016 SUMMER DAY CAMP REGISTRATION YMCA OF BEAUFORT County SITE LOCATION $15 Online Registrations / family $25 In person Registration / family Weekly Fees: Please see Camp Brochure 2016 SUMMER DAY CAMP REGISTRATION YMCA OF BEAUFORT County SITE LOCATION I have attached a valid

More information

W p m. Parent Manual& Map. a C ea

W p m. Parent Manual& Map. a C ea N R A E L Ca GR O 2015 LORE EXP l i W dcat W p m PLAY COVER DIS Parent Manual& Map s u p n o m i t a C ea Recr SO WHAT S THIS CAMP ALL ABOUT? COUNSELORS: Our staff is made up primarily of college students

More information

7 th Annual CHICAGO JAZZ PHILHARMONIC

7 th Annual CHICAGO JAZZ PHILHARMONIC 7 th Annual CHICAGO JAZZ PHILHARMONIC Dear Students and Parents: Welcome to the 7 th Annual CJP Jazz Academy. We have an exciting jazz program lined up for the 2 weeks you will be part of our family. Chicago

More information

WELCOME TO YMCA Teen Scene Middle School Enrichment Program (This sheet is for parents to keep for informational purposes)

WELCOME TO YMCA Teen Scene Middle School Enrichment Program (This sheet is for parents to keep for informational purposes) Robert D. Fowler Family YMCA Middle School Enrichment Program Student Registration Form 2015-16 Ivy Prep Academy Program Hours: 7am-7:45am & 4pm-7pm Transportation AM: Group leaves at 7:30am Transportation

More information

This registration form is also accessible online at: https://www.csuohio.edu/business/gyes-2015

This registration form is also accessible online at: https://www.csuohio.edu/business/gyes-2015 STUDENT REGISTRATION FORM Camp Session Dates: June 22, 2015- June 26, 2015 This registration form is also accessible online at: https://www.csuohio.edu/business/gyes-2015 Last Name: First Name: M.I.: Preferred

More information

2015 FUMC Hurst Youth Missions: SAN ANTONIO Permission, Liability Waiver, and Medical Release Form

2015 FUMC Hurst Youth Missions: SAN ANTONIO Permission, Liability Waiver, and Medical Release Form Permission, Liability Waiver, and Medical Release Form I give permission to participate in activities of the Youth or Children s Division of the First United Methodist Church, Hurst, Texas for the dates

More information

MIDDLE SCHOOL ACADEMIC ENRICHMENT PROGRAM REGISTRATION FORM 2015-2016

MIDDLE SCHOOL ACADEMIC ENRICHMENT PROGRAM REGISTRATION FORM 2015-2016 MIDDLE SCHOOL ACADEMIC ENRICHMENT PROGRAM REGISTRATION FORM 2015-2016 * Each form must be accompanied by a NON-REFUNDABLE, NON-TRANSFERABLE 10% deposit * Registration begins Monday, April 27, 2015 * Registration

More information

Learning Pathways Preschool Enrollment Application

Learning Pathways Preschool Enrollment Application Learning Pathways Preschool Enrollment Application Please check the location that you wish to enroll your child 4115 Jacksol Drive, San Jose 831 Malone Road, San Jose Program Enrollment (Please check one):

More information

GATEWAY DISCOVERY CAMP

GATEWAY DISCOVERY CAMP GATEWAY DISCOVERY CAMP SUMMER 2 0 1 6 REGISTRATION FORM Gateway Science Museum will host three sessions of the Gateway Discovery Camp. All sessions run 9am to 3pm and include daily snacks and lunches.

More information

Montessori Children s House Registration Form. Child s Name: Start date: Place of Employment. Place of Employment

Montessori Children s House Registration Form. Child s Name: Start date: Place of Employment. Place of Employment Montessori Children s House Registration Form Child s Name: Start date: Date of Birth: Nickname: Mother s Name: Mother s Address: Contact Numbers Place of Employment Work Address Work Phone Social Security

More information

CAMP MSC SENSATIONAL SUMMER SCIENCE

CAMP MSC SENSATIONAL SUMMER SCIENCE CAMP MSC SENSATIONAL SUMMER SCIENCE Thank you for choosing Camp MSC for your summer camp experience. Our camp programs are designed to be engaging, hands-on, challenging, and of course, fun! All full day

More information

Please email: tchin@sbnature2.org for more details.

Please email: tchin@sbnature2.org for more details. Medication Protocol: All medications (both over-the-counter and prescribed) must be cleared by the camper s guardian (additionally all prescribed meds must be cleared by a Physician) by filling out the

More information

SMOKY MOUNTAIN CHRISTIAN CAMP REGISTRATION SUMMER 2016

SMOKY MOUNTAIN CHRISTIAN CAMP REGISTRATION SUMMER 2016 SMOKY MOUNTAIN CHRISTIAN CAMP REGISTRATION SUMMER 2016 Student s Name: Grade Entering: Date of Birth: / / Gender Male Female Address: City, State, Zip: Home Phone ( ) Email: Parent s Name(s): *Parent s

More information

Nova Medical & Urgent Care Center, Inc Financial Policy

Nova Medical & Urgent Care Center, Inc Financial Policy Welcome and thank you for choosing Nova Medical & Urgent Care Center, Inc (hereafter referred to as Nova ) for your medical care. We are committed to providing you with the highest quality medical care

More information

CAMP MSC SENSATIONAL SUMMER SCIENCE

CAMP MSC SENSATIONAL SUMMER SCIENCE CAMP MSC SENSATIONAL SUMMER SCIENCE Thank you for choosing Camp MSC for your summer camp experience. Our camp programs are designed to be engaging, hands-on, challenging, and of course, fun! All full day

More information

J UNE 15 - AUGUST 7 GRADES (going into) HEADSTART - 7th grade

J UNE 15 - AUGUST 7 GRADES (going into) HEADSTART - 7th grade J UNE 15 - AUGUST 7 GRADES (going into) HEADSTART - 7th grade Our day camp offers structured activities from 8:00 a.m. to 5:00 p.m., 5 days a week for an eight-week program, all at one low price. Children

More information

A GREAT START TO THE DAY

A GREAT START TO THE DAY A GREAT START TO THE DAY GREATER BURLINGTON YMCA Before School Program Essex Elementary WELCOME TO Y BEFORE SCHOOL The Y knows kids. And we understand the needs of working families. Our Before School programs

More information

Oberlin Dance Intensive

Oberlin Dance Intensive Oberlin Dance Intensive July 6-11, 2014 For Ages 14-18 Early Registration Deadline: March 1, 2014 = $585 tuition Regular Registration Deadline: April 10, 2014 = $625 tuition Email completed registration

More information

LATE PAYMENT FEES WITHDRAWAL FROM THE PROGRAM THIRD PARTY (SPLIT) PAYMENTS RESPONSIBLE PARTY. Parent/Guardian Agreement: Dear Parents and Guardians,

LATE PAYMENT FEES WITHDRAWAL FROM THE PROGRAM THIRD PARTY (SPLIT) PAYMENTS RESPONSIBLE PARTY. Parent/Guardian Agreement: Dear Parents and Guardians, Dear Parents and Guardians, In order to simplify and provide better service to everyone, Rancho Simi Recreation and Park District ( the District ) has implemented the following payment processing procedures

More information

KU Summer Camp Registration Form 09 Please Print Clearly Due May 1, 2009 * REQUIRED INFORMATION

KU Summer Camp Registration Form 09 Please Print Clearly Due May 1, 2009 * REQUIRED INFORMATION KU Summer Camp Registration Form 09 Please Print Clearly Due May 1, 2009 * REQUIRED INFORMATION 1 *Participant: *Name of School: *Name of Coach: *Camper/Commuter: Check One: June Cheer Camp June Dance

More information

Registration 2012 Summer (Available 7am - 6pm) Child s Full Name: Name Used: Date of Birth: Gender: Grade: Full Address:

Registration 2012 Summer (Available 7am - 6pm) Child s Full Name: Name Used: Date of Birth: Gender: Grade: Full Address: ZION CHRISTIAN CHILDREN S CENTER SCHOOL AGE SUMMER CAMP Zion United Methodist Church ~ 1674 Zion Road Troy, VA 22974 (434) 906-5494 ~ ZionUMCAfterschool@gmail.com Registration 2012 Summer (Available 7am

More information

STEP 2: Please complete the Special Needs and Circumstances Section. STEP 3: Please take a moment to complete our questionnaire.

STEP 2: Please complete the Special Needs and Circumstances Section. STEP 3: Please take a moment to complete our questionnaire. New Rising Star Missionary Baptist Church Rising Stars Enrichment Program Registration Packet 7400 London Avenue, Eastlake Birmingham, Alabama 35206 Phone: (205) 833-3676 Email Address: risingstarscamp@nrschurch.org

More information

Johns Creek Montessori School Of Georgia

Johns Creek Montessori School Of Georgia ENROLLMENT FORM Pre-Primary (Toddler) Primary Half Day Full Day All Day Start : Child s Information: Child s Name Street Address Nickname of Birth Subdivision Name Primary Language Spoken Parent/Guardian

More information

Name: Location: Phone:

Name: Location: Phone: Welcome to our practice. Please complete all sections below. The signature of the patient, the custodial parent, or the legally responsible party is required. Please print all information. PATIENT INFORMATION:

More information

Rainbows of Learning School Age Child Care Program At Frankford Township School

Rainbows of Learning School Age Child Care Program At Frankford Township School Rainbows of Learning School Age Child Care Program At Frankford Township School Parent/Guardian #1 Name: Address: Employer: Parent/Guardian #2 Name: Address: Employer: Child s Name: Birth date: Gender:

More information

Emerald Hills Junior Golf Camp - Summer 2016. 938 WILMINGTON WAY REDWOOD CITY, CA 94062 www.playemeraldhills.com E-Mail - jrgolf.ehgc@gmail.

Emerald Hills Junior Golf Camp - Summer 2016. 938 WILMINGTON WAY REDWOOD CITY, CA 94062 www.playemeraldhills.com E-Mail - jrgolf.ehgc@gmail. OUR CAMPS ARE FOR GIRLS AND BOYS (AGES 5 THRU 14) Visit our website at Junior Golf Camp (9:00am 12:30pm) We start camp early (8:45am) on Monday for check-in and orientation. The camp is designed for beginners

More information

VOS - J.E.W.E.L.S Ani v Atah Student Application 2012-13

VOS - J.E.W.E.L.S Ani v Atah Student Application 2012-13 VOS - J.E.W.E.L.S Ani v Atah Student Application 2012-13 Student Information Name Middle Name Hebrew Name Address Number & Street City Zip Student s Email Student s Phone Male Female Date of Birth Entering

More information

Wyckoff Administration Policy on Epinephrine Nurse, Student and or Delegate

Wyckoff Administration Policy on Epinephrine Nurse, Student and or Delegate Wyckoff Administration Policy on Epinephrine Nurse, Student and or Delegate It is the policy of this school to apply New Jersey Law N.J.S.A. 18A: 40-12.3-12.6 in the following way: The school will provide

More information

GCA Summer Camp 2016 Overview

GCA Summer Camp 2016 Overview GCA Summer Camp 2016 Overview Ages: Preschool to 6th Grade Registration Fee: FREE if registered by May 2nd; $15 per week if registered after May 2nd. Tuition Fee: $125 per weekly session.* This includes

More information

Registration Form Please Check: Boy Girl Age: Camper s Name: Address: City: State: Zip Code:

Registration Form Please Check: Boy Girl Age: Camper s Name: Address: City: State: Zip Code: Registration Form Please Check: Boy Girl Age: Camper s Name: Address: City: State: Zip Code: Contact Name: Emergency Contact Number: Alt. Emergency Contact Number: E-Mail Address: Alt. Contact Name: Check

More information

Initial. Registration Packet. Summer Academy June 3 rd to August 30 th Z M G. www.zmgtennis.com. HP and TTT Registration Form 1 ZMG Tennis, LLC

Initial. Registration Packet. Summer Academy June 3 rd to August 30 th Z M G. www.zmgtennis.com. HP and TTT Registration Form 1 ZMG Tennis, LLC Registration Packet Summer Academy June 3 rd to August 30 th Z M G www.zmgtennis.com HP and TTT Registration Form 1, LLC Enrolment Process prides its self on offering everything essential in the development

More information

Name: Age: Gender: F M DOB: Address: County: Grade:

Name: Age: Gender: F M DOB: Address: County: Grade: Registration Due June 1, 2015 4-H Teen Camp - Outer Banks 2015 June 22-25, 2015 Thisexcitingcampforourteen44HmemberswilltakeustothecoastJoinusaswelearnaboutduneecology, marinebiology,northcarolinacoastalhistory,teambuilding,andleadershipskills.activitieswillincludeadolphin

More information

CONTRACT FOR PRIVATE MUSIC INSTRUCTION

CONTRACT FOR PRIVATE MUSIC INSTRUCTION CONTRACT FOR PRIVATE MUSIC INSTRUCTION I. GENERAL CONDITIONS i. Lessons will be offered over the academic year in each of the instruments for which the student is registered. Students will be scheduled

More information

WELCOME TO COASTLINE COMMUNITY COLLEGE!

WELCOME TO COASTLINE COMMUNITY COLLEGE! WELCOME TO COASTLINE COMMUNITY COLLEGE! Dear Prospective Student: Thank you for your inquiry regarding. We are pleased that you are considering our college as you make plans for your education. Enclosed

More information

2016/2017 Preschool Registration Form

2016/2017 Preschool Registration Form 105 135 Robin Cres. Saskatoon, SK S7L 6M3 Ph: 306-244-7820 Fax: 306-244-0089 office@bgcsaskatoon.com www.bgcsaskatoon.com 2016/2017 Preschool Registration Form BILINGUAL PRESCHOOL AT ECOLE COLLEGE PARK:

More information

Camp Horizon. 2015 Registration Packet. Non-Resident registration begins March 1 st. Camp Dates: June 22 to August 14 8 sessions

Camp Horizon. 2015 Registration Packet. Non-Resident registration begins March 1 st. Camp Dates: June 22 to August 14 8 sessions Camp Horizon (ages 5 12) 2015 Registration Packet Camp Dates: June 22 to August 14 8 sessions Ocean City Resident and Property Owner registration begins February 1 st Non-Resident registration begins March

More information

January 2016. Dear Families and Campers,

January 2016. Dear Families and Campers, YWCA Bergen County 112 Oak Street Ridgewood, NJ 07450 T: 201-201-444-5600 F: 201-447-9699 www.ywcabergencounty.org January 2016 Dear Families and Campers, Thank you for choosing the YWCA Bergen County

More information

RARITAN BAY AREA YMCA

RARITAN BAY AREA YMCA Dear Applicant, Enclosed please find the Youth Leaders & Junior Counselor In Training Application and the Camp Registration Packet. Please complete the application and return all documents with your $100.00

More information

CHITIMACHA TRIBAL SCHOOL. AFTER SCHOOL CARE PROGRAM Beginning Monday, August 17, 2015 ENROLLMENT PACKET 2015-2016

CHITIMACHA TRIBAL SCHOOL. AFTER SCHOOL CARE PROGRAM Beginning Monday, August 17, 2015 ENROLLMENT PACKET 2015-2016 CHITIMACHA TRIBAL SCHOOL AFTER SCHOOL CARE PROGRAM Beginning Monday, August 17, 2015 ENROLLMENT PACKET 2015-2016 After School Care Program Registration Please read and complete all information contained

More information

YMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM

YMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM YMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM Branch: North Brooklyn YMCA Camp Site: North Brooklyn Branch Camp Type: PARTICIPANT INFO Child s Name Age D.O.B. Gender Grade in September 2016 School

More information

Regulation 757-3 STUDENTS November 13, 2013 STUDENTS. Student Health Services and Requirements

Regulation 757-3 STUDENTS November 13, 2013 STUDENTS. Student Health Services and Requirements STUDENTS November 13, 2013 STUDENTS Student Health Services and Requirements Guidelines for School Staff/Child Care Contractor (CCC) to Carry Out Health Treatment Procedure and/or Emergency Treatment Procedures

More information

Aquaculture, Biology, and Conservation Summer Camp 2015 Registration Forms

Aquaculture, Biology, and Conservation Summer Camp 2015 Registration Forms Aquaculture, Biology, and Conservation Summer Camp 2015 Registration Forms All forms and payment are due no later than June 15, 2015 Note: There is a $25 non-refundable registration fee, and no refunds

More information

CONTRACT. Southwest Tour. Arkansas and Texas

CONTRACT. Southwest Tour. Arkansas and Texas 27 th Annual Tour CONTRACT Southwest Tour Arkansas and Texas APRIL 3 rd April 10, 2016 COLLEGES and UNIVERSITIES (Tentative) Arkansas Baptist College, Huston-Tillotson University, Jarvis Christian College,

More information

Medical Information. Page 1 of 5. Emergency Contact (other than Parent/Guardian): Name (First): Name (Last): Birth date: Age: Sex:

Medical Information. Page 1 of 5. Emergency Contact (other than Parent/Guardian): Name (First): Name (Last): Birth date: Age: Sex: Medical Information Name (First): Name (Last): Birth date: Age: Sex: Parent or guardian: Home Relationship to camper: Second Parent or guardian (or spouse): Home Relationship to camper: Emergency Contact

More information

Serving the Lord and loving His kids! Pastor Marjorie Bailey Pastor DeVona Cordell Pastor Judy Carney

Serving the Lord and loving His kids! Pastor Marjorie Bailey Pastor DeVona Cordell Pastor Judy Carney Campers, Parents & Church Leaders! We are SO EXCITED about Children s/pre-teen Camp. This year our theme is Turn It Up!!! Every kid loves a good story, whether it s a book, a movie, or a video game. So

More information

(US citizens under 18 must apply for the ISP guardianship program) Agent? Yes No Agency Name: Agency Contact Person: Street: Country, Zip code :

(US citizens under 18 must apply for the ISP guardianship program) Agent? Yes No Agency Name: Agency Contact Person: Street: Country, Zip code : Last Name (family name) INTERNATIONAL STUDENT PLACEMENTS COLLEGE PROGRAM APPLICATION Attach recent photo here (smiling) Birthdate: Age: Male Female Month / Day / Year (US citizens under 18 must apply for

More information

Helen Troum Nursery and Kindergarten at Temple Beth Sholom 40-25 Fair Lawn Ave, Fair Lawn, NJ 07410 201 797-2865

Helen Troum Nursery and Kindergarten at Temple Beth Sholom 40-25 Fair Lawn Ave, Fair Lawn, NJ 07410 201 797-2865 Helen Troum Nursery and Kindergarten at Temple Beth Sholom 40-25 Fair Lawn Ave, Fair Lawn, NJ 07410 201 797-2865 dlesnoytbs@yahoo.com Enrollment Contract and Registration Form 2016-2017 School Year I hereby

More information

East Hartford YMCA 770 Main St. East Hartford, CT 06108. Dear YMCA Family,

East Hartford YMCA 770 Main St. East Hartford, CT 06108. Dear YMCA Family, s Dear YMCA Family, Thank you for choosing the East Hartford YMCA for your early childhood education needs. We are excited to welcome you and your family to our program! The Y s focus is on youth development,

More information

West Virginia University 2015 Forensic Science Summer Camp

West Virginia University 2015 Forensic Science Summer Camp Thank you for registering for the! This packet contains the following forms that must be completed and returned before the student will be allowed to attend camp: Participant Information Form Event Participant

More information

juilliard.edu/summerjazz

juilliard.edu/summerjazz Juilliard JAZZ Summer 2013 Camp in Atlanta,GA June 17-21, 2013 One-week program for dedicated and disciplined students ages 12-18, who are passionate about jazz music For details see Juilliard s Web site:

More information

Registration Form. Child s Name: Grade: Age:

Registration Form. Child s Name: Grade: Age: Parent s Name: Address: Email Address: Cell Phone: Emergency Contact Name: Registration Form Home Phone: Number: Child s Name: Grade: Age: School Name: Gender: Male: Female: T-Shirt Size: Small: { } Medium:

More information

2015 Registration Guide

2015 Registration Guide 2015 Registration Guide In this guide, you will find: Steps for Registration Timeline for Registration and Promotion Move Information Overview (blank) Day of Move Checklist Move 2015 Registration Policy

More information

STEPS TO ADMISSION We recommend that interested parents schedule a campus tour.

STEPS TO ADMISSION We recommend that interested parents schedule a campus tour. So the generations to come might know Him Psalm 78:4 STEPS TO ADMISSION We recommend that interested parents schedule a campus tour. Application Process 1. Complete and return the application with the

More information

Georgia Tech North Ave. NW Atlanta Ga. 30332

Georgia Tech North Ave. NW Atlanta Ga. 30332 Welcome to Fun Weird STEM Saturdays 2014 The functioning objective of Fun Weird Science STEM Saturdays is to: 1. Provide students with hands-on STEM experience; and 2. Engage students in the exciting ways

More information

TSF Player Invitation Inter Academy Program U9-U12 Boys & Girls

TSF Player Invitation Inter Academy Program U9-U12 Boys & Girls TSF Player Invitation Inter Academy Program U9-U12 Boys & Girls TSF Academy would like to extend an invitation to play soccer with our Inter Academy Program. We are very excited about the upcoming season.

More information

Chatham Community Center Fitness Room

Chatham Community Center Fitness Room Chatham Park & Recreation 702 Main Street Chatham, MA 02633 Telephone Fax (508) 945-5159 www.chathamcommunitycenter.com Fitness Room Hours of Operation: Monday Saturday 8:00 A.M. to 9:00 P.M. Sundays 1-5:00

More information

Steps Steele Pilates Teacher Certification Program Application Checklist (International Students)

Steps Steele Pilates Teacher Certification Program Application Checklist (International Students) Steps Steele Pilates Teacher Certification Program Application Checklist (International Students) Items to be included in your Application Packet*: Completed application checklist Completed application

More information

Each child receives a camp T-shirt, a free tackle box and rod and reel that they will use throughout the week and take home with them on Friday.

Each child receives a camp T-shirt, a free tackle box and rod and reel that they will use throughout the week and take home with them on Friday. Campers ages 7 13 will learn about fishing techniques, conservation, marine biology and will participate in fun environmental fishing games. Our Angling weeks are filled with many cool fishing adventures.

More information

The Center for ADHD, Inc.

The Center for ADHD, Inc. Consent to Evaluate and Treat Date: Patient: Age: Date of Birth Female Male Black Hispanic White Other Address: City, State, Zip Code: Home Phone: Work/Cell: Person(s) Responsible for Payment: Address

More information

LEARN TO DRIVE LTD DRIVING SCHOOL

LEARN TO DRIVE LTD DRIVING SCHOOL Dear Parent: LEARN TO DRIVE LTD Please find enclosed a Driver Training School Agreement, an Emergency Medical Form/Direction Sheet, and an Addendum To Training Agreement (cancellation policy) for your

More information

Address: Street City State Zip Code Home Phone: E-mail Address:

Address: Street City State Zip Code Home Phone: E-mail Address: SANDWICH CUSD #430 REGISTRATION FORM SCHOOL YEAR 2013-2014 SELECT AN ATTENDANCE CENTER LG Haskin Prairie View WW Woodbury HE Dummer Middle School High School 1. NAME: 5. SEX: Male Female Last Name First

More information

Summer Camp at Inter-American Magnet School June 22nd through August 24th, 2015

Summer Camp at Inter-American Magnet School June 22nd through August 24th, 2015 Summer Camp at Inter-American Magnet School June 22nd through August 24th, 2015 Join us this summer as we travel to Spanish speaking countries across the world! We will feature activities that highlight

More information

TUITION RATES SCHOOL YEAR 2015-2016

TUITION RATES SCHOOL YEAR 2015-2016 TUITION RATES SCHOOL YEAR 2015-2016 REGISTRATION FEE: $65.00 per child DISCOUNTS: Family discount apply to families with two or more children in the Extended Day program. Full price is paid for the youngest

More information

OFFICE OF CATHOLIC SCHOOLS ARCHDIOCESE OF CHICAGO

OFFICE OF CATHOLIC SCHOOLS ARCHDIOCESE OF CHICAGO OFFICE OF CATHOLIC SCHOOLS ARCHDIOCESE OF CHICAGO SCHOOL MEDICATION PROCEDURES Parents/guardians have the primary respomibility for (he adminislration of medical ion to their children. The administration

More information

2016 VENTURA COUNTY JUNIOR LIFEGUARD PROGRAM HELD ON SILVER STRAND BEACH IN OXNARD

2016 VENTURA COUNTY JUNIOR LIFEGUARD PROGRAM HELD ON SILVER STRAND BEACH IN OXNARD 2016 VENTURA COUNTY JUNIOR LIFEGUARD PROGRAM HELD ON SILVER STRAND BEACH IN OXNARD Dear Junior Lifeguard Families and prospective Junior Lifeguards: Enclosed is your 2016 PROGRAM OUTLINE. Please retain

More information

Before and After School Enrichment General Information, 2015-2016

Before and After School Enrichment General Information, 2015-2016 Before and After School Enrichment General Information, 2015-2016 Care Site/Title XX Authorization Schools Served Location Times DeWitt YMCA BASE DeWitt DeWitt Elementary 425 Falls Ave Cuyahoga Falls,

More information

WHAT TO BRING TO CAMP Backpack

WHAT TO BRING TO CAMP Backpack JOHNSTON YMCA DAY CAMP FAQ Q. What does my child need to bring to camp? A. Swimsuit, towel, tennis shoes, comfortable clothing, book bag, and journal (provided). Please also apply waterproof sunscreen/bug

More information

2015 Annual Patient Paperwork Update for Existing Patients

2015 Annual Patient Paperwork Update for Existing Patients 2015 Annual Patient Paperwork Update for Existing Patients DATE: ͺͺͺͺ ŚĞĐŬ WƌĞĨĞƌƌĞĚ ůŝŷŝđ &ƚ tăljŷğ 'ƌğğŷǁžžě

More information

Date: Student s Name DOB / / Age!!! (First)!! (Middle)!! (Last) Preferred name. Student s School Grade Level Dismissal Time

Date: Student s Name DOB / / Age!!! (First)!! (Middle)!! (Last) Preferred name. Student s School Grade Level Dismissal Time Lafayette Theatre Academy Registration Form Date: Student s Name DOB / / Age!!! (First)!! (Middle)!! (Last) Preferred name Student s School Grade Level Dismissal Time Parent/Guardian/Account Holder s Information

More information

UNIVERSITY OF NEBRASKA AT OMAHA CHILD CARE CENTER CONTRACT/AGREEMENT

UNIVERSITY OF NEBRASKA AT OMAHA CHILD CARE CENTER CONTRACT/AGREEMENT UNIVERSITY OF NEBRASKA AT OMAHA CHILD CARE CENTER CONTRACT/AGREEMENT I agree to pay on the first day my child(ren) attends the center, a weekly tuition fee of $, with no deductions for absences or non-major

More information

JUNE 20 24, 2016 VIDEO GAME DEVELOPMENT SUMMER CAMP

JUNE 20 24, 2016 VIDEO GAME DEVELOPMENT SUMMER CAMP Attention upcoming 7 th - 10 th graders: You are invited to join the IT and Web Design faculty at Carteret Community College for an action packed week of Video Game Design, Development, and Play. JUNE

More information

California State University, Los Angeles English Language Program (ELP)

California State University, Los Angeles English Language Program (ELP) (ELP) Application Checklist Students must be at least 18 years of age by the program start date. The (ELP) requires a student (F-1) visa. Your application cannot be processed until all required documents

More information

I authorize the Center for ADHD, Inc./R. Timothy Brown, M.D. to evaluate and treat.

I authorize the Center for ADHD, Inc./R. Timothy Brown, M.D. to evaluate and treat. CENTER FOR ADHD, INC. AND R. TIMOTHY BROWN, M.D., LLC Consent to Evaluate and Treat Patient: Age: Date of Birth: Female Male Black Hispanic White Other Address: City, State, Zip Code: Home Phone: Business/Cell

More information

2210 High Tech Road, State College, PA 16803 814-357-6898 fax 814-357-6897 www.pennskates.com

2210 High Tech Road, State College, PA 16803 814-357-6898 fax 814-357-6897 www.pennskates.com Dear Summer Camp Parents, 2210 High Tech Road, State College, PA 16803 814-357-6898 fax 814-357-6897 www.pennskates.com Welcome to our 2015 Summer Day Camp program! Your children will have the opportunity

More information