Summer at Landmark Registration W orksheet Redding 3s 5s - Student Name
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Summer at Landmark Registration Worksheet
Redding 3s 5s
Student Name_____________________________ Age (as of 12/31/2018) _________________
Summer at Landmark Payment Information
Redding 3s 5s
Student Name_____________________________ Age (as of 12/31/2018) __________________
Please Note:
● There are no sessions the week of July 2, 2018
● Children in this program must turn three by December 31st, 2018 and must be toilet trained.
Payment Information:
● You must register with the total “due at registration” (make checks payable to: Ridgefield Academy).
● All final payments will be due no later than June 17th.
● Late payments will be subject to a $25 late fee charge and will jeopardize participation in the program.
● Landmark Preschool reserves the right to cancel any session due to low enrollment. Refunds will be
issued for any cancelled session.
Payment Method:
❑ Cash
❑ Check – Number__________
❑ Credit Card (circle one) Visa Mastercard American Express
Card Number: __________________________________________________________________________
Exp. Date: ____________________ Cardholder Signature: _________________________________
Payment Amount
❑ I authorize my credit card to be drafted for only the amount due at registration.
❑ Please draft the total amount due for all sessions
Amount Paid: $____________ Balance Remaining: $______________
For more information please visit our website at www.landmarkpreschool.org
or call the Main Office at (203) 544-8393SUMMER SESSIONS 2018 REGISTRATION FORM – REDDING CAMPUS Use a separate form for each camper and please print all information clearly. General Information Child’s Name (First) ____________________________________ (Last) ____________________________ Sex M/F Mother’s Name (First) ___________________________________ (Last) ________________________________ Father’s Name (First) ____________________________________ (Last) _______________________________ Mailing Address _____________________________________________________________________________ City ________________________________________ State ___________________ Zip ___________________ Child’s Age (as of 6/2018) ______ Date of Birth ___________ Child’s Grade (entering 9/2018) ______________ Child’s Home Phone ____________________________ Mother’s Work Phone ____________________________ Mother’s Cell Phone ___________________________ Father’s Work Phone ____________________________ Father’s Cell Phone ____________________________ Emergency Information Please list two emergency contacts (other than parents): Name ________________________________________ Relationship___________________________________ Home Phone __________________________________ Work/Cell Phone _______________________________ Name ________________________________________ Relationship___________________________________ Home Phone __________________________________ Work/Cell Phone _______________________________ Pick Up Authorization The following people are authorized to pick up my child (other than parents): Name _______________________________________ Day Time Phone __________________________________ Name _______________________________________ Day Time Phone __________________________________ Name _______________________________________ Day Time Phone __________________________________ Permission Slip I, ____________________________, the parent/guardian of ____________________________, understand that Ridgefield Academy is a non-profit organization which makes it facilities, programs and activities available to persons only on the condition that they agree to assume complete responsibility for any injury or damage. I acknowledge that Ridgefield Academy programs and activities may involve risk, and assume those risks for my child. Further, in consideration of acceptance of my child into the Ridgefield Academy camp and/or its sponsored programs and activities, I release and agree to hold harmless Ridgefield Academy, its officers, directors, employees and staff from any claims or damage or loss (including but not limited to physical injury, and property damage) that may occur as a result of my child’s participation in any Ridgefield Academy sponsored program or activity. I hereby give the foregoing release on behalf of myself, my child, and all family members of either of us, and confirm that I authorize to do so. I understand that Ridgefield Academy does not carry medical/accident insurance, and that I am responsible for any and all charges for medical treatment, property damage, or acquiring my own insurance. I acknowledge that participation in Ridgefield Academy sponsored activities is conditional upon compliance with all applicable rules and policies established at Ridgefield Academy. I further acknowledge that Ridgefield Academy sponsored activities and participants may be photographed, filmed or videotaped from time to time, and hereby consent use of my child’s picture and likeness for Ridgefield Academy related promotional purposes without further consideration. Parent or Guardian Signature ____________________________________Date ________________ See Reverse
SUMMER SESSIONS 2018 MEDICAL BACKGROUND AND AUTHORIZATION
This form to be completed by a parent or legal guardian. Please print clearly.
Medical Concerns
Landmark requires background information on your child in order to provide licensed medical staff with pertinent information in
case of emergency. Please list any medical conditions we should be aware of.
Other comments: _________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Medications
Please list medications that your child is taking. We ask that, if at all possible, you medicate your child outside of camp hours.
However, if your child requires these medications during camp, please contact us for an authorization form.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Allergies and Allergic Reactions
Please note: If your child has a food allergy, we ask that you provide their own food items during the durations of camp
including snack and lunch.
Does your son/daughter react negatively to any medication or foods? If so, please list them.
____ Hay Fever ____ Poison Ivy ____ Insect Sting ____ Penicillin ____Foods
Other __________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Parent Authorization
The health history listed herein is correct as far as I know. I accept full responsibility for the health and physical condition of the
person herein described, and give my permission for him/her to engage in all Ridgefield Academy sponsored activities, except as
noted by me. In the event that I cannot be reached in an emergency, I hereby give my permission to the physician selected by
Ridgefield Academy to hospitalize, secure proper treatment or to order injection, anesthesia or surgery for my child as named
above.
Parent or Guardian Signature ___________________________________________________________ Date _____________
By State regulation your child may not attend camp until this form is fully completed and
returned, along with a recent Immunization Form to Landmark Preschool.You can also read
