Summer Camp Admissions

Is your child a 2 years old?*
2 yr olds and ONLY 2 yr olds can choose 2, 3, or 5 days a week. If your child is OLDER than 2, check NO.
- Yes
- No

2 year old Options
Please indicate how many days you want your 2 yr. old to attend. Please skip if your child is OLDER than 2.
- 2 Days a week
- 3 Days a week
- 5 Days a week

Child's Name (Name Child Goes By):*
First Last
Child's gender*
- Boy
- Girl
Immersion Program*
Is your child currently enrolled in a Spanish Immersion Program?
- Yes
- No
Child's Birth Date*
All children must be be 2 years old by June 1, 2019.

Authorized Carpool Pickup
Please list the people that you would like to authorize to pick up your child. We will not release your child, under any circumstance, to anyone other than his/her parents without written permission.
First Carpool Contact
First Last
First Carpool Contact Phone
Second Carpool Contact
First Last
Second Carpool Contact Phone
Emergency Contact
Please list local persons other than regular carpool drivers that we may call in case of an emergency if you cannot be reached and that has permission to pick up your child.
First Emergency Contact Name*
We will contact this person after attempting to contact Parent 1 and Parent 2.
First Last
First Emergency Contact Phone*
Second Emergency Contact Name
First Last
Second Emergency Contact Phone

Medical Information
Child's Physician*
First Last
Physician's Phone Number*
Insurance Company*
Insurance Company Phone Number*
Insurance Group Number*
Insurance Company Address*
Street Address Address Line 2 City State ZIP Code
Health Problems, Allergies, or other important information
Please list any allergies, health concerns, or other important information we should know about your child. Please make sure your child's teachers and the school Director understand the severity of any allergies.
Symptoms displayed when having an allergic reaction:
Emergency Medical Agreement*
Should my child suffer an injury or illness while in the care of The Spanish Academy, and the school is unable to contact me (us) immediately, it shall be authorized to secure medical attention and care for my child as may be necessary. I (we) assume responsibility for payment of services. I (we) agree to keep the school informed of changes in telephone numbers where I (we) can be reached.
- I have read and agree to abide by the policies listed above.
Policies*
*Absolutely no refunds will be made.

*All children enrolled at The Spanish Academy are required to have health insurance.

*Candid pictures and video of children at The Spanish Academy may be used for advertising purposes.
- I have read and agree to abide by the policies listed above.

SUMMER CAMP ENROLLMENT BEGINS ON 2/4/2019