Day Camp Registration Form Step 1 of 4 25% Registration DetailsParent Name* First Last Email Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mobile Phone*Child DetailsChild's Name* First Last Child's Date of Birth*Current SoulShiner?*YesNoSchool AttendedGradeCamp DetailsSelected Day Camp*Purchase Lunch for Day Camp?*YesNo Save and Continue Later Day Camp Family AgreementTRANSPORTATION.* I hereby give consent for my child to be transported and supervised by the operation’s employees. FIELD TRIPS.* I hereby give consent for my child to participate in field trips. WATER ACTIVITIES. I hereby give consent for my child to participate in these water activities:* Sprinkler Play Splashing/Wading Pools Swimming Pools Water Table Play VIDEO/PHOTOGRAPHY. I give permission for my child to be photographed and videotaped for use by or on behalf of the facility for education, training, curriculum, marketing and similar purposes.*YesNoMEDICATION, I authorize SoulShine to apply one or more of the following topical ointments/preparations to my child in accordance with the directions on the label of the container:* Band Aids Neosporin or similar ointment Bactine or first-aid spray Sunscreen Insect repellent Non-prescription ointment (such as A& D, Vaseline) Benadryl (for fever or allergic reaction) Tylenol (for fever or allergic reaction) Other (please specify below) None of these Other Medications AllowedPlease enter the other medication(s) SoulShine is authorized to apply SAFETY.* I understand my child will not be allowed to enter or leave the facility without being escorted by the parent(s), person authorized by parent(s) or SoulShine personnel. RECORDS.* I acknowledge it is my responsibility to keep my child's records current and to update any significant changes as they occur (e.g., phone numbers, work location, emergency contacts, child's physician, child's health status) INCIDENT REPORTS.* I understand that SoulShine agrees to keep me informed of any incidents, including illness, injuries, adverse reactions to medications, or exposure to communicable diseases which may include my child. PARENT HANDBOOK.* I have downloaded, reviewed and understand the Parent Handbook and related information concerning SoulShine's Day Camp services. REGISTRATION AND PAYMENTS.* I understand that registration must be fully completed prior to my child attending SoulShine Day Camp. Where applicable, all registration and/or tuition fees must be paid on or before the first day of camp. #1 Parent/Guardian Name as Signature* First Last ACCEPT NAME AS SIGNATURE (Parent/Guardian #1)* Please accept my printed name above as my signature on this agreement #2 Parent/Guardian Name as Signature First Last ACCEPT NAME AS SIGNATURE (Parent/Guardian #2) Please accept my printed name above as my signature on this agreement Save and Continue Later Emergency InformationEmergency Contacts*Click the + sign to add up to three emergency contactsNameRelationshipPhone Number Authorized Pick-Ups. Picture ID will be required.*Click the + sign to add up to three additional individuals authorized to pick up your child. If this does not apply, enter NONameRelationshipPhone Number Is there any person(s) who are NOT authorized to pick up your child for any reason?*If this does not apply, please enter NODoes your child have any allergies or food sensitivities?*YesNoPlease list your child's allergies or food sensitivities here. If there is an allergy, an Allergy Action Plan will be required.Please list any childhood diseases and/or serious illnesses your child has experienced*If none, please enter NO Save and Continue Later Medical & Licensing NotificationsSOULSHINE MEDICAL EMERGENCY POLICY In the event of a medical emergency SoulShine will attempt to contact the parents and/or designated emergency contact persons. If these individuals cannot be reached, “911” will be called in order to have the most immediate medical help available for the needs of the child. If a contacted individual cannot pick up the child, and there is a medical emergency, SoulShine will release the child to the paramedics. A staff person will accompany the child and paramedics to Children’s Healthcare of Atlanta (Egleston Hospital). I hereby give permission for my child, named below, to be given first aid by the SoulShine staff and/or to be treated by paramedics. I understand that the policy of SoulShine is to first attempt to contact me by phone. If I am unreachable, SoulShine may treat or authorize treatment and/or may transport or authorize transportation by ambulance to Children’s Healthcare of Atlanta (Egleston Hospital) in the case of a medical emergency. Medical Permission granted for Child:* Child's First Name Child's Last Name #1 Parent/Guardian Initials to grant permission for medical treatment*#2 Parent/Guardian Initials to grant permission for medical treatmentLicense Exemption NotificationIt is important that you be informed that SoulShine After School has been granted an exemption from licensing through Bright from the Start. This means that our program is NOT licensed. Submit Registration By placing my signature below, I verify that I have been advised and understand that SoulShine After School (Day Camp) is not licensed by Bright from the Start, Georgia’s Department of Early Care and Learning. I verify that all information I have provided is accurate and complete. I realize that failure to provide accurate information about my child may jeopardize enrollment in this program. I further verify that no information has been omitted. #1 Parent/Guardian Name* First Last ACCEPT NAME AS SIGNATURE (Parent/Guardian #1)* Please accept my printed name above as my signature on this agreement #2 Parent/Guardian Name First Last ACCEPT NAME AS SIGNATURE (Parent/Guardian #2) Please accept my printed name above as my signature on this agreement Submission Date* PhoneThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.