www.caseysplace.org
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REGISTRATION & FORMS
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Parental Authorization and Release Form
EVENTS
CAMP REGISTRATION
*
Indicates required field
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Date Of Birth
*
Age
*
Gender
*
Male
Female
Home Phone Number
*
Other Emergency Number
*
Mom's Cellphone Number
*
Dad's Cellphone Number
*
Best Email
*
Mom's Work Number
*
Dad's Work Number
*
Fees
$35.00 Daily, Monday - Friday, 7:00 am - 6:00 pm
$150.00 Weekly, Monday - Friday, 7:00 am to 6:00 pm
(You will be charged the full weekly rate even if your child is sick, on vacation, or just doesn't want to come, etc)
$50 non-refundable registration fee for 1 child ($75 for multiple children) is required to register your child for either Daily or Weekly Camps.
Scholarships available on sliding scale. Call to make an appointment to discuss.
Week Of:
*
Initial to approve the right to charge for late pick ups
*
Parents Initial
Initial to acknowledge that payment is due in full on the first day of week
*
Parents Initial
Methods Of Payment
We accept cash, check, Venmo (Caseys-Place-25), or Zelle (2142648637) .
We will be closed for the following holidays:
Memorial Day
July 4th Independence Day
Additional Information and/or Comments
Medical Conditions: (check all that apply: __ADHD__ADD __Autism __Other
*
List ALL Medications taking:
*
Allergies to Medications
*
Allergies to Foods:
*
Allergies to Laundry Detergents/Fabric Softeners/Chemicals/other:
*
Doctors Name
*
Doctors Phone Number
*
Medical Insurance
*
Policy Number
*
Food / Drink my child LOVES
*
Food / Drink my child DOES NOT LIKE
*
Hobbies or Interests
*
Does your child attend Church, if yes, where?
*
I Hereby do give/do not give permission for the following for my child
Apply / Give Benadryl as needed
*
Yes
No
Apply Sunscreen as needed
*
Yes
No
Authorize to treat an emergency and/or perform CPR
*
Yes
No
Any other notes or concerns that we should be aware of such as mental health issues, special needs, or certain triggers or any fears like water, dogs, etc. PLEASE BE SPECIFIC!!
*
I Hereby authorize my child to be picked up ONLY by the following persons. In case of an emergency and I can not be reached, I authorize Casey's Place to contact
Name
*
Phone Number
*
Relationship
*
In Case Of
*
Pick-Up
Emergency
Name
*
Relationship
*
Phone Number
*
In Case Of
*
Pick-Up
Emergency
Name
*
Relationship
*
Phone Number
*
In Case Of
*
Pick-Up
Emergency
Required Supplies for Summer
Swimming attire-bathing suits (no bikinis). Sunblock, beach towel, water shoes or flip flops, water bottle. Extra set of clothes (we will maintain clothes as needed)**Boys are required to wear shirts with their bathing suits**
Closed toed shoes are to be worn at all times on the farm unless swimming.
If you have any further questions, please feel free to contact us at 972-932-5156 or by email
[email protected]
Submitter Signature
*
Submit
Don't forget to submit the Parental Authorization and release form!
