REGISTRATION FORM

Please complete mail or fax over 770-484-7162AINFORMATION Please type or print legibly.

Last Name: First Name:

Gender: ¨ Female ¨ Male

Age:_____________

Parents Name:____________________________________________

Address:

City: State/Province: Zip Code:_________

Telephone: _____________________________       Fax: ________________________________

Email: _______________________________________________________________________

ncludes breakfast, lunch and snack

Registration Fee: $25.00

Weekly tuition: $75.00

Field Trips: additional fees apply PAYMENT METHOD – Full payment is due prior to receiving conference confirmation.

Please see registration information for details. Checks/money orders must be in U.S. funds payable to: The Harvest Tabernacle. There will be a $25.00 fee charged on checks returned by the bank due to insufficient funds.

Payment Type:           Check     VISA    MasterCard     Money Order     Cash

Cardholder’s Name: _____________________________________________

Card Number:  _________________________________________________

Expiration Date: _____________________       Verification Code:________       Billing ZIP:  ________

 

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AUTHORIZATION TO LEAVE CARE

 

For your child’s safety, s/he can only be allowed to leave the program with (1) you (the person enrolling the child); (2) persons you have listed below; and (optional) (3) a person not listed below in an emergency, when:

(a) you have told the program in person or by phone that the person is coming to pick up the child, and (b) you send a signed & dated note with that person authorizing the release of the child

My child, ________________________________ may leave Camp Harvest with the following people:

Relationship to child, Name, Phone

1. ____________________________________________________________

2. _____________________________________________________________

3. _____________________________________________________________

4._____________________________________________________________

 

_____________________________________________________________

(Parent’s Signature) (Date)

 

 

 

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MEDICAL AUTHORIZATION FORM

 

I. Family Information

Child’s Name_______________________ Birth date________________

Parent’s Name________________________________________

Home phone___________________ Work phone______________________

 

II. Additional persons who can be called in an emergency:

Name________________________________ Phone_____________________

Relationship____________________________

Name_________________________________ Phone____________________

Relationship____________________________

 

III. Physician to be called in emergency:

Name______________________________ Phone___________________________

Address______________________________________________________________

If physician cannot be reached, what action should be taken?

 

IV. Medical insurance information:

Group Name/Plan Number:___________________________________________________________

Name and Social Security # of Insured (or person responsible for payment):__________________________________________________________

V. Allergies or other medical limitations:_____________________________________________________________________________________________________________________________________

VI. Permission for medical treatment: In case of accident or emergency, I authorize Camp Harvest’s authorized adults to take my child to the above-named physician or to the nearest hospital for emergency treatment. I authorize the administration of measures as are deemed necessary for the safety and protection of the child.

 

 

________________________________________________

(Parent’s Signature) (Date)

 

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FIELD TRIP AUTHORIZATION FORM

 

Child’s Name:_________________________________________________

I give my permission for my child to go on field trips listed below under the supervision of Camp Harvest. I have current emergency information and medical release forms on file with the center. (as each trip arises separate permission slips with pertinent information will be made available)

 

______________________________________________

(Parent’s Signature) (Date)

 

Center for puppetry arts

Zoo Atlanta

Chucky cheese

Indoor jumping facility

Six flags

New world of coca cola

American Adventure

Stone Mountain Park

The children’s museum of art

Movie Theater

Swimming Pool

Skating

Dr. Martin Luther King District