305-713-9528
info@ateliermelodie.com

Summer Camp Registration

Child’s Name:

Date of birth:

School currently attending:

Child’s age:

Parent/Guardian:

Primary Address:

City:

State:

Zip:

Phone:

Mobile:

Email:


Emergency Information

Emergency Contacts

Person 1:

Relationship:

Phone:

Person 2:

Relationship:

Phone:

Allergies and/or Medical Conditions:

Physician’s name:

Phone:


Camp Policies

People authorized to pick up your child:

1.

2.

3.

4.


Please read and initial

Potty Trained - Children must be potty trained. We understand accidents happen, but following repeated incidents Atelier Mélodie will notify rents and recommend the child transfer to an Early Childhood Institute Camp.

Behavior Expectations - In an effort to provide all campers with a safe and fun-filled camp experience, all campers must exhibit proper behavior and self-control. Inappropriate, disruptive and or violent behavior while at camp will not be tolerated. Atelier Mélodie reserves the right, upon notification of parents, to dismiss any child for improper conduct.

Personal Items - I understand that Atelier Mélodie cannot be held responsible for the loss, destruction or theft of any personal items. Please leave toys, games and electronic devices at home.

Media Release - I authorize Atelier Mélodie to photograph and/ video- tape my child for publicity purposes. Materials will not be sold or loaned.

I understand that Atelier Mélodie will make every reasonable effort to provide a safe environment. I am fully aware of the special dangers and risks inherent in participating in the activities, including physical injury, or other consequences arising or resulting from the activities.

I have read and understand the above camp policies and procedures.

Parent/Guardian Printed Name:

Date:

Parent/Guardian Signature: