Monday, Oct. 8, Playing Life Academy School Break Camp

Monday, Oct. 8, Playing Life Academy School Break Camp
Enrollment Form and Parental/Guardian Agreement
* This form is required for PLA School Break campers. It should accompany online and snail mail enrollments. It
can be scanned and e-mailed or snail mailed.
* Complete one form for each camper.
* E-mail to [email protected] or mail to: Playing Life Academy, 1645 Fourth Street, Berkeley,
California, 94710.
Camper Name:_______________________________________________________________________________
First
Last
Middle
Address:_____________________________________________________________________________________
Number and Street
City
State
ZIP
School___________________ DOB:___/___/___ Age:____ M____ F____ Email:__________________________
Parent/Guardian 1:________________________________ PH#________________________________________
Parent/Guardian 2:________________________________ PH#________________________________________
Physician:_________________ PH#________________Dentist:___________________ PH#_________________
Insurance:____________________________________ Policy#_________________________________________
Emergency contacts and camp pick up/drop off list:
Name_____________________________Relationship_____________________PH#________________________
Name____________________________ Relationship_____________________PH#________________________
Name _____________________________Relationship_____________________PH#_______________________
How did you find out about Playing Life Academy Camp? ____________________________________________
In order to assist us in providing the best camp experience for your camper:
* Please describe any diagnosable special needs, such as food allergies, or behavioral issues,
including the preferred plan of action. The information you provide will be held in confidence.
* Please describe anything we should know about your camper. (Friends at camp, etc.?)
1
Monday, October 8, Playing Life Academy School Break Camp Enrollment Form and Parental/Guardian Agreement,
pg.2
CAMPER NAME ____________________
AGE ________
Program Hours: 9am-3pm
Extended Care: 8-9am and 3-6pm
Circle:
BOY
GIRL
Please check enrollment options:
Program Fee: $65
Extended Care Fee: FREE if enrolled by
Thurs., Oct. 4, $10-25 after Oct. 4
_____ attending morning care, 8-9 am
Drop off/Pick up: Playing Life Academy,
1645 4th Street, Berkeley
approximate drop-off/pick-up times___________
_____ attending afternoon care, 3-6 pm
PARENTAL/GUARDIAN AGREEMENT
_
Recognizing that School Break Camp, Monday, October 8, a Playing Life Academy program, will do its best
to ensure a safe experience, I understand, agree and acknowledge that some activities may be of a hazardous
nature and/or include physical and/or strenuous activity and that sport training and recreational activities may
include physical contact and may include walking off-site to local parks and/or businesses.
I understand that I am required to disclose an officially diagnosed special need and/or any disruptive
behavioral issue of my son/daughter, hereafter referred to as “the camper listed in this form”. Such disclosure is
necessary for the well being and safety of the camper listed in this form and that of all School Break Camp
participants. I recognize that failure to disclose such may adversely affect the participation of the camper listed in
this form. Understanding this, I state to the best of my knowledge that the camper listed in this form has no
medical conditions or behavioral issues that would hinder his/her active participation in School Break Camps at
Playing Life Academy.
In the case of injury, I authorize the Staff of Playing Life Academy School Break Camps to render first aid
and/or obtain whatever medical treatment he/she deems necessary for the welfare of the camper listed in this
form. I further understand and agree that I will be financially responsible for all charges and fees incurred in the
rendering of said treatment, regardless of whether my insurance would cover such charges and fees.
I understand that Playing Life Academy School Break Camps reserves the right to cancel camp in the
event of an emergency, such as a natural disaster, and/or the camp site becomes inaccessible for use, and that
Staff will contact me as soon as is feasible with pertinent information. I understand the cancellation of camp may
require early pick-up of the child listed in this form.
I understand and agree I am assuming full and voluntary responsibility and knowingly assume all such
risks entailed by emergencies, natural disasters, death or personal injury, property loss, or damage suffered by the
camper listed in this form.
Knowing this and by signing this Parental/Guardian Consent Agreement Form, I am agreeing to release,
indemnify and hold Playing Life Academy School Break Camps and Staff harmless forever from any and all liability
costs, including attorney fees, associated with or arising from the participation of the camper listed in this form in
Playing Life Academy School Break Camps.
I understand, and give my consent for images (photos, video footage, etc.) of the camper listed in this
form at Playing Life Academy School Break Camps to be used for promotional purposes in the future.
I am the parent or legal guardian of the camper listed in this form. I have read, understood, and agree to
the terms and conditions of this form, and understand that I am giving up substantial rights including my right to
sue. I acknowledge I am signing this Agreement freely and voluntarily, and intend by my signature a complete and
unconditional release of all liability to the greatest extent allowed by law.
____________________________________________________________________________________
Signature
Date
2