Rock. Learn. N Play. 2019 Summer Camp Registration Form June 24 - August 23, 2019 Question Title * 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. Name Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number OK Question Title * 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. Name Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number OK Question Title * 3. Name and Contact Details of Person Responsible for Child(ren) Pickup Name of Primary Person Responsible for Pickup Telephone Number of Primary Person Responsible for Pickup Name of Secondary Person Responsible for Pickup Telephone Number of Secondary Person Responsible for Pickup OK Question Title * 4. Name of Child Attending the Rock.Learn.N Play. Summer Camp Child (1) Name Date of Birth (MM/DD/YY) Gender Grade Address where child resides Child (2) Name Date of Birth (MM/DD/YY) Gender Grade Address where child resides Child (3) Name Date of Birth (MM/DD/YY) Gender Grade Address where child resides OK Question Title * 5. Medical Information Release (Copy of child's Immunization records required on 1st day camp) Name of Primary Physician for Child Hospital Name or Healthcare Name Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number OK Question Title * 6. Is the above medical information for all the children listed in this registration form? Yes No, provide physician information for each of the children in the space provided below Please enter physician information for each of the other children listed in this regisration form if you answered 'no' above. OK Question Title * 7. What is your hospital preference for the following? Child (1) as listed in this form above Child (2) as listed in this form above Child (3) as listed in this form above OK Question Title * 8. Please provide medical considerations for your child(ren) that we should know about and your instructions on addressing these. Food allergies Medication allergies Other allergies Asthma Seizure(s) Diabetes Other Other OK Question Title * 9. For the medical concerns listed above, please provide us with treatment instructions below. OK Question Title * 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. Paramedic should be called in the event of an incident involving the medical concern. Yes Paramedic should be called in the event of an incident involving the medical concern. No OK Question Title * 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. OK Question Title * 12. Please provide detailed food restrictions and/or information about special diet or dietary restrictions. OK Question Title * 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. Yes, I give permission No, I do not give permission OK Question Title * 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 Full program, June 24 to August 23, $2,900 Child (1) Full program, June 24 to August 23, $2,900 Child (2) Full program, June 24 to August 23, $2,900 Child (3) Week of June 24, $400 Week of June 24, $400 Child (1) Week of June 24, $400 Child (2) Week of June 24, $400 Child (3) Week of July 1, $400 Week of July 1, $400 Child (1) Week of July 1, $400 Child (2) Week of July 1, $400 Child (3) Week of July 8, $400 Week of July 8, $400 Child (1) Week of July 8, $400 Child (2) Week of July 8, $400 Child (3) Week of July 15, $400 Week of July 15, $400 Child (1) Week of July 15, $400 Child (2) Week of July 15, $400 Child (3) Week of July 22, $400 Week of July 22, $400 Child (1) Week of July 22, $400 Child (2) Week of July 22, $400 Child (3) Week of July 29, $400 Week of July 29, $400 Child (1) Week of July 29, $400 Child (2) Week of July 29, $400 Child (3) Week of August 5, $400 Week of August 5, $400 Child (1) Week of August 5, $400 Child (2) Week of August 5, $400 Child (3) Week of August 12, $400 Week of August 12, $400 Child (1) Week of August 12, $400 Child (2) Week of August 12, $400 Child (3) Week of August 19, $400 Week of August 19, $400 Child (1) Week of August 19, $400 Child (2) Week of August 19, $400 Child (3) OK 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, #335Montclair, NJ 070422. Make payments securely online at www.rocklearnplay.com 3. Call Beatrice at 917.292.4866 for payments over the phone OK DONE
