2020 SUMMER REGISTRATION2020 SUMMER REGISTRATION
Child’s Name _______________________________________________________________________________________________________________________
Last First Middle
Child’s Birthdate ________________________________________________________________________________________________ ■ Female ■ Male
Month Date Year
Age At Camp___________________________________ Grade Next Fall_____________________ School ____________________________________________
Child’s T-Shirt Size: ■■ Small (6-8) ■■ Medium (10-12) ■■ Large (14-16) ■■ Adult Small ■■ Adult Medium ■■ Adult Large
Resides with(Check One): ■■ Both Parents ■■ Mother ■■ Father ■■ Other–Legal Guardian Name ____________________________________________
Parent/Guardian 1 Name _______________________________ Cell Phone ______________________ Daytime Number ________________________________
Alternate Number _______________________ Address __________________________________________ City/Zip_________________________________
Business Name and Address___________________________________________________________ E-mail __________________________________________
Parent/Guardian 2 Name _______________________________ Cell Phone ______________________ Daytime Number ________________________________
Alternate Number _______________________ Address __________________________________________ City/Zip_________________________________
Business Name and Address___________________________________________________________ E-mail __________________________________________
Child may be released to ■■ Parent/ ■■ Parent/ ■■ Other 1. ____________________________ 2. _________________________________________
Guardian1
Guardian2
3. ____________________________ 4. _________________________________________
Emergency Contact(s) (other than parents) _______________________________________________________________________________________________
Name Relationship Phone
Child’s Physician ____________________________________________________________________________________________________________________
Name Phone
Hospital preferred Health insurance program
for emergency treatment ____________________________________ and identification number __________________________________________________
Any dietary, food or allergy restrictions? _________________________________________________________________________________________________
Any medical instructions? _____________________________________________________________________________________________________________
Friends to be grouped with (limit 2) ____________________________________________________________________________________________________
Interests or special abilities: Art, Dance, Sports, etc. _______________________________________________________________________________________
Prior camp experience ■■ Summer Impressions ■■ Other (please specify) __________________________________________________________________
Where did you hear about Summer Impressions? __________________________________________________________________________________________
Is there additional information that would help us better care for your child? (Ex: glasses, shyness, tubes in ears, etc.) _____________________________
____________________________________________________________________________________________________________________
It is understood that Summer Impressions Day Camp, Inc. has the right to request the withdrawal from the camp of any child for reasons in its sole discretion at any time. It is con-
templated, but not limited to, situations involving a child or parent/guardian’s failure to abide by the rules and procedures set by the camp; conduct or influence of parent or child
deemed by the camp to be unsuitable for continuation in the program; a child who is not benefitting from the program; any flexibilities in enrollment and such other situations as may
arise. If only one parent signs this agreement, that parent agrees that he/she is also acting as an agent of the other parent with authority to enroll the child at camp.
I grant permission for taking and/or using my child’s name and image for any purpose, including educational and advertisement purposes, and in any medium, including print and elec-
tronic. I further waive any claim, including claims for compensation, of any kind for the taking, use or publication.
I give permission to Summer Impressions Day Camp, Inc. to secure emergency medical treatment for the above named child if required when the parent(s)/guardian and/or emergency
contacts cannot be reached. I agree to send my child with a nutritional lunch. I give my permission for my child to participate in all camp activities including field trips and enclose a
$200 deposit, payable to Summer Impressions Day Camp, 4150 Middlebelt Road, West Bloomfield, MI 48323. I further agree and understand that this $200 deposit and all prepaid
tuition are non-refundable and non-transferable for any reason whatsoever including but not limited to absences due to illness, surgery, communicable diseases, vacation, withdrawal,
holidays, or any other unforeseen circumstances, etc.
Signature __________________________________________________________________________________________________________________________
Parent or Legal Guardian Date
Signature __________________________________________________________________________________________________________________________
Parent or Legal Guardian Date
Please reserve the following camp sessions:
■■ Mini Camp I ■■ Session I ■■ Session II ■■ Session III ■■ Mini Camp II ■■ Mini Camp III
(1 week) (3 weeks) (3 weeks) (3 weeks) (1 week) (M-TH Only)
June 15 - June 19 June 22 - July 10 July 13 - July 31 Aug. 3 - Aug. 21 Aug. 24 - Aug. 28 Aug. 31 - Sept. 3
Schedule Monday Tuesday Wednesday Thursday Friday
FULL DAY
(9:00 a.m. - 3:30 p.m.)
EXTENDED CARE
(7:00 a.m. - 6:00 p.m.)
(7:00 a.m. - 3:30 p.m.)
(9:00 a.m. - 6:00 p.m.)
Please print clearly:
NO
ADDITIONAL
CHARGE!
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