LPT DAY CAMP 2013 REGISTRATION FORM
| INSTRUCTIONS: Complete, print and mail with a $35.00 non-refundable reservation fee per child to: LPT Day Camp 2512 McHenry Dr. Silver Spring, MD 20904 |
LPT DAY CAMP
2512 McHenry Dr.
Silver Spring, MD 20904
2014 REGISTRATION AND CONSENT FORM
Child's Name:_____________________________________
Birth date: _______________
Parent/Guardian #1 Name:
________________________________________________________________
Telephone: Home_________________ Work____________________
Cell _________________________
Email:_______________________________
Parent/Guardian #2 Name:
_________________________________________________________________
Telephone: Home_________________ Work____________________
Cell _________________________
Email:_______________________________
EMERGENCY CONTACTS (to whom child may be released if guardian is unavailable)
Name #1:
___________________________________________Relationship__________________________
Telephone: Home_________________ Work____________________
Cell___________________________
Name #2:___________________________________________
Relationship__________________________
Telephone: Home_________________ Work____________________
Cell__________________
NO one will be permitted to pick up this camper from camp without your permission.
CHILD'S PREFERRED SOURCES OF MEDICAL CARE
Physician's Name:
_______________________________________________________________________
Address:_____________________________________Telephone:________________
Dentist's Name:
_________________________________________________________________________
Address:_____________________________________Telephone:________________
Hospital Name:
__________________________________________________________________________
Address:
_____________________________________________Telephone____________________
Ambulance Service:
_________________________________________________________________________
Address:
_____________________________________________Telephone:__________________
(Parents are responsible for all emergency transportation charges.)
CHILD'S HEALTH INSURANCE
Insurance Plan:__________________________________________________
ID#_____________________
Subscriber's Name (on insurance card):
______________________________________________________
SPECIAL CONDITIONS, DISABILITIES, ALLERGIES, OR MEDICAL EMERGENCY
INFORMATION
_________________________________________________________________________________________
_________________________________________________________________________________________
I understand that medications can only be administered with a completed Physician’s
Medication Order form signed by the prescribing doctor.
I understand that the directors of LPT reserve the right to suspend any camper for
any length of time when it is necessary in the best interest of the camper or the
camp.
I understand that full tuition must be paid in full by Monday morning of the impending
week of camp. We will accept a post dated check that is negotiable by Wednesday
morning. If by Wednesday morning payment is still not received, by child(ren) will
not be permitted to participate in the rest of the week of camp.
I give permission for LPT Day Camp to use my child image, voice, testimony, and/or
picture in any type of promotional material. Yes_____ NO_____
I understand a $35.00 non-refundable reservation fee per camper must be included
with this registration form.
I understand there will be a $25.00 fee for each returned check.
I give permission for the LPT Camp staff and any agency action on its behalf to
provide medical attention that might be necessary and urgent during a time when I
cannot be contacted by telephone.
I give permission for child(ren) to participate in all camp activities, realizing that
every safety precaution will be taken at all times but that LPT Day Camp assumes no
liability for injuries or damage resulting from regular participation.
I understand my child(ren) cannot begin any week of camp until the registration form
is fully completed, including the date of the last tetanus shot.
By signing my name, I indicate that I have read and have understood each of the
above statements, and agree to relate with LPT Day Camp in a way that reflects my
understanding of the above statements.
PARENT/GUARDIAN CONSENT AND AGREEMENT FOR EMERGENCIES
As parent/guardian, I consent to have my child receive first aid by facility staff and, if
necessary, be transported to receive emergency care. I will be responsible for all
charges not covered by insurance. I give consent for the emergency contact person
listed above to act on my behalf until I am available. I agree to review and update this
information whenever a change occurs and at least every 6 months.
Parent/Guardian Signature_____________________________________________
Date_________________
Parent/Guardian Signature_____________________________________________
Date_________________
If you have any question, please do not hesitate to contact us via phone: 301-792-
3108 or 1264
All campers are required to wear a LPT Day Camp t-shirt on trips (cost is part of
registration fee).
T-shirts size (circle one): Youth-medium (10-12) Youth-large(14-16)
Adult-small Adult-medium Adult-large Adult-x large Adult-2xlarge
Circle the weeks you wish this camper to attend:
1. June 16-20 2. June 23-27
3. June 30-4(closed) 4. July 7-11
5. July 14-18 6. July 21-25
7. July 28-Aug 1 8. Aug 1-5
9. Aug 4-8 10. Aug 11-15
11. Aug 18-22 12. Aug 25-29
2512 McHenry Dr.
Silver Spring, MD 20904
2014 REGISTRATION AND CONSENT FORM
Child's Name:_____________________________________
Birth date: _______________
Parent/Guardian #1 Name:
________________________________________________________________
Telephone: Home_________________ Work____________________
Cell _________________________
Email:_______________________________
Parent/Guardian #2 Name:
_________________________________________________________________
Telephone: Home_________________ Work____________________
Cell _________________________
Email:_______________________________
EMERGENCY CONTACTS (to whom child may be released if guardian is unavailable)
Name #1:
___________________________________________Relationship__________________________
Telephone: Home_________________ Work____________________
Cell___________________________
Name #2:___________________________________________
Relationship__________________________
Telephone: Home_________________ Work____________________
Cell__________________
NO one will be permitted to pick up this camper from camp without your permission.
CHILD'S PREFERRED SOURCES OF MEDICAL CARE
Physician's Name:
_______________________________________________________________________
Address:_____________________________________Telephone:________________
Dentist's Name:
_________________________________________________________________________
Address:_____________________________________Telephone:________________
Hospital Name:
__________________________________________________________________________
Address:
_____________________________________________Telephone____________________
Ambulance Service:
_________________________________________________________________________
Address:
_____________________________________________Telephone:__________________
(Parents are responsible for all emergency transportation charges.)
CHILD'S HEALTH INSURANCE
Insurance Plan:__________________________________________________
ID#_____________________
Subscriber's Name (on insurance card):
______________________________________________________
SPECIAL CONDITIONS, DISABILITIES, ALLERGIES, OR MEDICAL EMERGENCY
INFORMATION
_________________________________________________________________________________________
_________________________________________________________________________________________
I understand that medications can only be administered with a completed Physician’s
Medication Order form signed by the prescribing doctor.
I understand that the directors of LPT reserve the right to suspend any camper for
any length of time when it is necessary in the best interest of the camper or the
camp.
I understand that full tuition must be paid in full by Monday morning of the impending
week of camp. We will accept a post dated check that is negotiable by Wednesday
morning. If by Wednesday morning payment is still not received, by child(ren) will
not be permitted to participate in the rest of the week of camp.
I give permission for LPT Day Camp to use my child image, voice, testimony, and/or
picture in any type of promotional material. Yes_____ NO_____
I understand a $35.00 non-refundable reservation fee per camper must be included
with this registration form.
I understand there will be a $25.00 fee for each returned check.
I give permission for the LPT Camp staff and any agency action on its behalf to
provide medical attention that might be necessary and urgent during a time when I
cannot be contacted by telephone.
I give permission for child(ren) to participate in all camp activities, realizing that
every safety precaution will be taken at all times but that LPT Day Camp assumes no
liability for injuries or damage resulting from regular participation.
I understand my child(ren) cannot begin any week of camp until the registration form
is fully completed, including the date of the last tetanus shot.
By signing my name, I indicate that I have read and have understood each of the
above statements, and agree to relate with LPT Day Camp in a way that reflects my
understanding of the above statements.
PARENT/GUARDIAN CONSENT AND AGREEMENT FOR EMERGENCIES
As parent/guardian, I consent to have my child receive first aid by facility staff and, if
necessary, be transported to receive emergency care. I will be responsible for all
charges not covered by insurance. I give consent for the emergency contact person
listed above to act on my behalf until I am available. I agree to review and update this
information whenever a change occurs and at least every 6 months.
Parent/Guardian Signature_____________________________________________
Date_________________
Parent/Guardian Signature_____________________________________________
Date_________________
If you have any question, please do not hesitate to contact us via phone: 301-792-
3108 or 1264
All campers are required to wear a LPT Day Camp t-shirt on trips (cost is part of
registration fee).
T-shirts size (circle one): Youth-medium (10-12) Youth-large(14-16)
Adult-small Adult-medium Adult-large Adult-x large Adult-2xlarge
Circle the weeks you wish this camper to attend:
1. June 16-20 2. June 23-27
3. June 30-4(closed) 4. July 7-11
5. July 14-18 6. July 21-25
7. July 28-Aug 1 8. Aug 1-5
9. Aug 4-8 10. Aug 11-15
11. Aug 18-22 12. Aug 25-29
