![](3D"2007_Registration_Form_files/image002.gif")
Enrollment
Form
Please Print. Please fill out all
areas.
![](3D"2007_Registration_Form_files/image004.gif")
One child per form
Child’s Information
Camper’s Na=
me:
_________________________________________&n=
bsp; =
; Age:
________ =
; Birthday:
___________________
Grade (in the
fall) ________ Retained? : if yes, grade _________=
__ &=
nbsp; School
____________________________________________
Special
Interest/Hobbies ___________________________________ ____________________________________________________=
______
How well does your
child swim? Circle one &n=
bsp; Like
a Rock &nb=
sp; Doggy-paddle
Any reason(s) why
your child should be closely monitored during physical activities?
_______________________________________________
Academic Strength=
s:
______________________________________ =
; &n=
bsp; Academic
Weaknesses ________________________________
Miscellaneous Not=
es:
___________________________________________________________________________=
______________________
Parent/Guardian
Information
1) Parent/Guardia=
n:
____________________________________ &=
nbsp; &nbs=
p; 2)
Parent/Guardian: ____________________________________
Address:
______________________________________________ =
Address:
_____________________________________________
City, State, Zip
________________________________________&nb=
sp; =
City,
State, Zip ________________________________________
Home Phone:
___________________Cell___________________&=
nbsp; &nbs=
p; Home
Phone: ____________________Cell__________________
Work Phone:
____________________________x_____________&=
nbsp; &nbs=
p; Work
Phone: ____________________________x_____________
EMAIL:
_______________________________________________ =
; EMAIL:____________=
____________________________________
The following peo=
ple
may pick up my “camper”.
1.
___________________________ relationship _______________ =
3.
___________________________ relationship ______________
2.
___________________________ relationship _______________ =
4.
___________________________ relationship ______________
Emergency
Information
Name of person, other than parents/guardians, to con= tact in case of emergency:
Name
______________________________________________ =
Address
_______________________________________________
Home Phone
________________________________________&nb=
sp; =
______________________________________________________
Work Phone
________________________________________&nb=
sp; =
&nb=
sp; Relationship
to child ______________________________________
Name of Physician
___________________________________ &n=
bsp; =
; &n=
bsp; Address
________________________________________________
Phone
_____________________________________________ &=
nbsp; &nbs=
p; _______________________________________________________
Health/Medical
Allergies:
___________________________________________________________________________=
_________________________________________
Medical
Conditions:
___________________________________________________________________________=
_________________________________
Instructions
for medication
- Ple=
ase
fill out the portion below.
List the name of each medication that the child will be taking,=
the
correct dosage, and scheduled time during camp, and reason for the
medication. (If taking more than 2 medications please request a second
form).
- Kee=
p all
medication in the original package/bottle that identifies the patient
and/or the prescribing physician, the name of the medication, the dosa=
ge
and the frequency of administration.
- The
information written on this sheet must be exactly the same as the
information on the medication.
(If the two do not match, we will be unable to dispense the
medication).
- No =
over
the counter medications.
Name of Medicine
______________________________ &=
nbsp; Dosage
_____________ =
Times________________ Reason
____________________
Name of Medicine
______________________________ &=
nbsp; Dosage
_____________ =
Times________________ Reason
____________________
Parent/ Guardian Authorization
________________________________________________ Date
________________________________
Is your child=
new
to MFLC? Circle
one Yes
No =
; How did you h=
ear
about MFLC? &nb=
sp; Circle
one Word of Mouth Flyer<=
span
style=3D'mso-spacerun:yes'>
Newspaper Ad=
Web
Site
Banner &=
nbsp;
Yellow Pages
Other______________ What Size t-s=
hirt
does your camper wear? Circle
one <=
/span>Youth
S (6-8)
M (10-12)
L (14-16) <=
/span>Adult S<=
span
style=3D'mso-spacerun:yes'> M L XL
Office Use Only<=
/u>: Enrollment
fee: __________________ &nbs=
p; Date
_________________ Tuition
_________________________ &n=
bsp; Date
_________________ Amount
Due ____________________ &nb=
sp; Date
_________________
______&nbs=
p; I
have completed all of this form.