2019 Summer Camp Registration Form

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* 1. Parent and/or Guardian Name and Contact Details. This information will also be the Emergency Contact details. By providing your name and contact details below, you understand that you will be contacted in the event of medical, or other emergency involving your child(ren) listed in this registration form. In the event that you cannot be reached, you authorize Rock.Learn.N Play. to call the doctor and/or hospital to provide medical services in the event of an injury or illness. You understand that you will be responsible for all expenses relating to medical and/or other emergencies.

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* 2. Second Parent and/or Guardian Name and Contact Details. This information will also be the secondary Emergency Contact details. By providing your name and contact details below, you understand that you will be contacted in the event of medical, or other emergency involving your child(ren) listed in this registration form. In the event that you cannot be reached, you authorize Rock.Learn.N Play. to call the doctor and/or hospital to provide medical services in the event of an injury or illness. You understand that you will be responsible for all expenses relating to medical and/or other emergencies.

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* 3. Name and Contact Details of Person Responsible for Child(ren) Pickup

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* 4. Name of Child Attending the Rock.Learn.N Play. Summer Camp

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* 5. Medical Information Release (Copy of child's Immunization records
required on 1st day camp
)

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* 6. Is the above medical information for all the children listed in this registration form?

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* 7. What is your hospital preference for the following?

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* 8. Please provide medical considerations for your child(ren) that we should know about and your instructions on addressing these.

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* 9. For the medical concerns listed above, please provide us with treatment instructions below.

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* 10. For the medical concerns listed above, select one of the following.

  Yes No
Paramedic should be called in the event of an incident involving the medical concern.

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* 11. Is any of your child(ren) listed on this registration form being treated for an injury, sickness, or taking medication for any illness or condition? If yes, provide detailed explanation below.

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* 12. Please provide detailed food restrictions and/or information about special diet or dietary restrictions.

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* 13. Photo Release: I give Rock.Learn.N Play. permission to use my child(ren) photographs or photographic image in official Rock.Learn.N Play capacity. This may include usage for promotional material such as website, newsletters, etc. It will not always be possible for parents to inspect the finished products before they are distributed.

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* 14. Please indicate the schedule of the child(ren) you are registering for the summer camp with Rock.Learn. N Play. The daily hours of operation are Monday thru Friday, 7:30AM to 6:00PM, with the exception of July 4th, we will be closed.

  Child (1) Child (2) Child (3)
Full program, June 24 to August 23,  $2,900
Week of June 24, $400
Week of July 1, $400
Week of July 8, $400
Week of July 15, $400
Week of July 22, $400
Week of July 29, $400
Week of August 5, $400
Week of August 12, $400
Week of August 19, $400
Thank you for registering for Rock. Learn. 'N' Play. Summer Camp. We look forward to getting
to know, caring, supporting, and challenging your child(ren) in the age appropriate programs
we have compiled at Rock (music), Learn (STEAM Instruction), and Play (taekwondo and
indoor/outdoor activities).


Please make your payment(s) in the following ways:
1. Mail Check addressed to:
"Rock.Learn.N Play." 
41 Watchung Plaza, #335
Montclair, NJ 07042

2. Make payments securely online at www.rocklearnplay.com 

3. Call Beatrice at 917.292.4866 for payments over the phone

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