Camp Enrollment Form *If submitting for more than one child, please add additional children in questions box below. Make the form page Camper's Name:*Camper's date of birth* Date Format: MM slash DD slash YYYY Age*Gender*MaleFemaleCamper's NicknameCamper's Home Address:*Preferred contact number*Is your child potty trained?YesNoDoes your child have any allergies? If so please explain below.*List Any Needed Action. If None Write None.*EPIPENINHALERNONEDoes your child have any behavioral or emotional difficulties? If so please explain below.*ANY MEDICATIONS TAKEN ON A REGULAR BASIS:*LIST ANY UNUSUAL FACTOR'S IN CAMPER'S LIFE*Age as of September 30, 2018*Academic grade completed in June 2018:*Previous Child Day Care/ Schools Attended*Camper's Current School*Name(s) and Age(s) of Sibling(s):*Physician Name*Physician Address*Physician Phone*Parent 1:* First Last Home address (if same as camper write same)*Workplace:*Work Phone:*Preferred (cell):*Parent 2:* First Last Home address (if same as camper write same)*Workplace:*Work Phone:*Preferred (cell):*Work Phone:*1st Emergency Contact Name:*1st Emergency contact phone:*1st Emergency Contact Address1st Emergency Contact relation to child*2nd Emergency Contact Name:*2nd Emergency contact phone:*2nd Emergency Contact Address2nd Emergency Contact relation to child*Person(s) not authorized to pick up camper*Select your session:* All day (9-3:00) Morning Half day (9-12) Afternoon Half day (12:00-3:00) Dates you're interested in registering your camper.*PHOTO & VIDEO RELEASE WAIVER: Sometimes Once Upon A Dream takes pictures or videos for use in marketing and social media. Checking the box below grants Once Upon A Dream permission to use picture/video of your camper for these purposes.* Yes, I understand and accept the above Photo & Video Waiver. LIABILITY RELEASE WAIVER: By checking below, you release Once Upon A Dream from any liability for damages or injury that could arise as a result of participation in its camps. You give consent for 1) your child to participate in Once Upon A Dream Camp and 2) any emergency medical treatment that may be necessary as a result of participation in Once Upon A Dream Camp.* Yes, I understand and accept the above Liability Release. AGREEMENTS: By this application, 1. the parent(s)/guardian(s) agrees to follow the policies and procedures stated in the Once Upon A Dream Enrollment packet. 2. It is understood that the administration has all the responsibility for placement of the camper in the proper group, that the teacher has full discretion for classroom discipline, and that the school can dismiss campers for not respecting its spiritual, behavioral, and other requirements. 3. Parent(s)Guardian(s) agree to arrange to have the camper picked up as soon as possible upon notification of illness by Once Upon A Dream. 4. Authorization is given for the camper to participate in water play. 5. Authorization is given to release my child to anyone in the Contact/ Pick Up List above. 6. Parent(s)/Guardian(s) agree to notify the Once Upon A Dream Staff within 24 hours if anyone in the immediate family/household contracts a communicable disease. 7. The Parent(s)/ Guardian(s) are financially responsible for each week your child is enrolled regardless of attendance.* Yes, I understand and accept the above Agreements. Electronic Signature:*Email* Check here to receive email updates Today's date:* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.