| CHILD'S INFORMATION | |
| |
| Today's date: |
|
| Legal name: (first, middle, last) |
|
| Preferred first name: |
|
| Gender: |
Male
Female
|
| Date of birth (month, day, year): |
|
| Child's Soc. Sec. Number: |
|
| |
| PARENTS' INFORMATION | |
| |
| Father's name: |
|
| Address: |
|
| City: |
|
| State: |
|
| ZIP: |
|
| Home phone: |
|
| E-mail: |
|
| Occupation: |
|
| Employer: |
|
| Business address: |
|
| Business phone: |
|
| Business e-mail: |
|
| . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . |
| |
| Mother's name: |
|
| Address: |
|
| City: |
|
| State: |
|
| ZIP: |
|
| Home phone: |
|
| E-mail: |
|
| Occupation: |
|
| Employer: |
|
| Business address: |
|
| Business phone: |
|
| Business e-mail: |
|
| |
| CAMP CHOICES | (check either 2, 3 or 5 days next to the camp name) |
| |
| No. of days | Camp Name
|
| 2 3 5 |
June 4-8 | Under The Big Top |
2 3 5 |
June 11-15 | What's Cooking? |
2 3 5 |
June 18-22 | We Will Rock You! |
2 3 5 |
June 25-29 | To Infinity And Beyond |
2 3 5 |
July 2-6 | Er, We Are Pirates! |
2 3 5 |
July 9-13 | A Day In The Knight |
2 3 5 |
July 16-20 | Water Works |
2 3 5 |
July 23-27 | Marvel vs. DC Comics |
| |
| FAMILY INFORMATION | |
| |
| Child's siblings: |
|
|
Name: Age: |
|
Name: Age: |
|
Name: Age: |
| |
| With whom does the child reside? |
|
| |
Legal guardian’s name
and address, if applicable |
|
| |
Language spoken
in the home: |
English Other
(please specify below) |
| |
| PARENT STATEMENTS | |
| |
| Please help us know your child by providing the following
information. It is understood that young children continue
to grow and develop; your responses should describe
current circumstances.
|
| Personal Development: |
|
Yes
No
|
Has your child attended preschool/childcare before? |
| If yes, school name: |
|
|
Yes
No
|
Can your child feed her/himself using a spoon and/or fork? |
|
Yes
No
|
Wash and dry her/his own hands? |
|
Yes
No
|
Dress her/ himself with little assistance? |
|
Yes
No
|
Speak so that he/she can be understood by others? |
|
Yes
No
|
Express her/his thoughts and needs easily? |
|
Yes
No
|
Is your child toilet-trained during the day? |
| |
| Health History: |
|
Yes
No
|
Has your child ever had trouble seeing? |
|
Yes
No
|
Has your child had frequent ear infections? |
|
Yes
No
|
Does your child have allergies? |
|
Yes
No
|
Has your child had any significant injuries/hospitalizations? |
|
Yes
No
|
Is your child presently on any medications? |
| |
| If you responded "yes" to any of the above, please explain.
Also, describe any other health concerns.
|
|
|
| |
| Interests/Activities: |
|
Yes
No
|
Can your child play with blocks/building toys without help? |
|
Yes
No
|
Use crayons or markers to draw? |
|
Yes
No
|
Listen to stories being read out loud? |
|
Yes
No
|
Turn pages of a book and look at pictures? |
|
Yes
No
|
Recall stories and events? |
|
Yes
No
|
Enjoy playing alone or with imaginary friends? |
|
Yes
No
|
Follow simple, age-appropriate directions? |
|
Yes
No
|
Talk with your friends and relatives who come to visit? |
| |
| Please describe your child's favorite activities when
playing with other children: |
|
|
| Please describe your child's favorite activities when
playing alone: |
|
|
| Please describe your child's favorite activities when
at home with Mom or Dad: |
|
|
| Please share anything else we should know: |
|
|
| |
| DECLARATION | |
| |
| By checking the box below, I am stating that the information provided
here is truthful and accurate to the best of my knowledge. It is further
understood that any misstatement or omission may result in denial of
admission or enrollment.
I agree.
(To complete your application, click on the button below.)
|
| |
| |
| |
| |
| |
