ACC Summer Camp 2023 On Campus Program Registration Form

Select School

Incoming Grade Level

Date of Birth ( Must be 4 years or older by the day of this application)

Student’s First Name

Student’s Last Name

Gender

Parent/Guardian’s Full Name (1)

Tel

Email

Address

City / State

ZIP Code

Parent/Guardian’s Full Name (2)

Tel

Email

Emergency Contact Information
The following people are authorized to pick up the child listed above and may be contacted in the event of an emergency.
Authorized Person to Pick-Up Must Be 18 Years or Older

Contact 1 Full Name

Relationship

Tel

Email

Contact 2 Full Name

Relationship

Tel

Email

Contact 3 Full Name

Relationship

Tel

Email

Individuals Not Permitted To Pick Up The Camper
The following people are NOT authorized to pick up the child listed above.

Not Autorized Person 1

Not Autorized Person 2

T-shirt Size

Medical Information

ON CAMPUS PROGRAM: ACTIVITIES & FINANCIAL ENROLLMENT AGREEMENT OUTDOOR ACTIVITIES: Team Sports | Agility Test | Jump Rope | Jumping Jacks Competition | Endurance Challenge & more.
INDOOR ACTIVITIES: Computer Games | Arts & Crafts | Table Tennis | Karaoke Competition | Darts | Mind Games | Movies & more.
Pre-K4 to 8th Grade Registration Fee: $100 ( Non Refundable) .
Participation Fee Per Session: 2 Installments of $220 / week for a session of two weeks.
Participation Includes:

- activities,
- sports,
- lunch,
- field trip expenses for weeks 1, 3, 5, 7.
- Collectible ACC 2023 T-shirt.
10% Discount for 2nd and additional siblings
10% discount on the 2nd and consecutive sessions if:
- Enrolled in more than 2 sessions &
- All additional sessions are pre-paid in full
Hours of Operation: 7am – 6:00pm ($1 per minute after 6:00pm).
Field Trip and Activities subject to change or cancellation.
No discount for children who choose not to have Camp offered lunch.
No discount for children who choose not to attend the field trip.
Absences and cancellations are not refundable or transferable.
You may pay the registration fee and first installment over the phone by calling the school’s phone number 305-279-6572 and request to be connected with the cashier or by emailing the archimedean credit card authorization form (HERE)
Week 1 payment must to be paid with the registration
All forms and fees need to be completed and paid for your child to be fully registered to camp.

Not Included

Field trip for weeks 2, 4, 6 cost TBD per filed trip.

Program and/or Schedule may change or canceled due to unforeseen reasons.

Session Selection (Please select two or more sessions and respond with yes or no for all other sessions)

June 19th & July 4th Camp Closed.

Session 1 June 12th - June 23rd

Yes No

Session 2 June 26th - July 7th

Yes No

Session 3 July 10th - July 21st

Yes No

Session 4 July 24th - July 28th

Yes No

Parent Guardian Authorization

Parent Guardian Authorization Term 1:
I am hereby giving my permission for the child herein described to engage in all Camp activities.

Yes No

Parent Guardian Authorization Term 2
I hereby give my permission to the ACC to use photos and videos of my child as an ACC participant in promotional literature or media used by the ACC.

Yes No

Parent Guardian Authorization Term 3

I hereby give permission to the ACC Staff to take whatever emergency measures are judged necessary for the care and protection of my child while under their supervision. In case of a medical emergency I understand that my child will be transported to an appropriate medical facility by the local emergency unit for treatment, if the local emergency deems necessary. I understand that in some medical situations the ACC Staff will need to contact the local emergency resources before the parent/guardian. I understand that my expenses incurred will be covered by the child’s family insurance.

Parent Guardian Authorization Term 4

I understand that if my child is to attend the field trip he/she will be transported by bus. While in route, the child will be under the direct super- vision of the driver and ACC Staff and will be subject to all regulations set for the safety of the child. I will not hold the driver, the ACC Staff, nor the Archimedean Schools responsible for any injuries or loss of property which may be sustained as a direct or indirect result of this service.

Parent/Guardian Signature

Date