Little Harts Summer Camp

Registration & Release Form


(Please fill out one form for every child participating in camp)

Operation Name Director's Name
Little Harts Summer Camps Carol Barratt 214-923-0370
Child's Full Name Child's Date of Birth Child's Home Telephone No.
     
Child's Home Address
 
Date of Admission Email
   
Parent's or Guardian's Name Address (if different from child's address)
   
List telephone number below where parents/guardian may be reached while child will be in care:
Mother's Telephone No. Father's Telephone No. Guardian's Telephone No. Cell Phone No.
       
Give the name, address and phone number of the person to call in case of an emergency if parents/guardian cannot be reached:
Emergency Contact Name Emergency Contact Phone Emergency Contact Email
     
Emergency Contact Address Emergency Contact Relationship
   
I hereby authorize the childcare operation to allow my child to leave the childcare operation ONLY with the following persons. Please list name & telephone number for each. Children will only be released to a parent or a person designated by the parent/guardian after verification of ID.
     

CAMP REGISTRATION

Please check the box for each camp your child will attend.
 
 Week 1 
 Jun 3
  to Jun 7 
 Week 2 
 Jun 10
  to Jun 14 
 Week 3 
 Jun 17
  to Jun 21 
 Week 4 
 Jun 24
  to Jun 28 
 Week 5 
 Jul 1
  to Jul 5 
 Week 6 
 Jul 8
  to Jul 12 
 Week 7 
 Jul 15
  to Jul 19 
 Week 8 
 Jul 22
  to Jul 26 
 Week 9 
 Jul 29
  to Aug 2 
 Week 10 
 Aug 5
  to Aug 9 
 Week 11 
 Aug 12
  to Aug 16 
$90 per week
$90 per week
Chile / Peru
Brazil / Argentina
Venezuela / Paraguay
Mexico / Cuba
USA / Canada
South Africa / Ta nanni / Morocco
Ghana / Algeria
Spain / Italy / United Kingdom
France / Germany
Contact Bliss Easton (903) 819-8684
Contact Bliss Easton (903) 819-8684
$175 per week
$200 per

Please note: Children will be divided into different groups depending on their age.

If you are attending all summer or multiple weeks, it is not necessary to pay the full tuition up-front. Payment can be made the first Monday of each week of camp attended.

Please mail you completed Registration & Release Form with you initial payment to:

Carol Barratt
P.O. Box 913
McKinney, TX 75070

CHECK ALL THAT APPLY:     I hereby     give      do not give
1.    EQUINE ACTIVITIES
- consent for my children to participate in horse rides, pony cart rides, animal petting and grooming.
2.    WATER ACTIVITIES
(Wading pool, water table, sprinklers, etc.)
3.    RECEIPT OF WRITTEN OPERATIONAL POLICIES:
I acknowledge that I have reviewed the facilities operational policy including those of discipline and guidance that are found on the Little Harts Summer Camp web site (www.littleharts.com)
4.    I UNDERSTAND THAT AN AM SNACK AND A PM SNACK WILL BE PROVIDED TO MY CHILD AND THAT I AM TO PROVIDE LUNCH
  AM Snack               PM Snack
YOU MUST PROVIDE EITHER AN IMUNIZATION RECORD OR
THE ADDRESS AND PHONE # OF A SCHOOL WHERE YOUR CHILD'S IMMUNIZATION RECORD IS KEPT
SCHOOL AGE CHILDREN:

 
My child attends the following school:
Name of School and Address
School Ph.#
 
CHECK ALL THAT APPLY:

 
His / her immunization record is on file at the school and all required immunizations and/or tuberculosis test are current. Vision and Hearing screening records are also on file.
 
I have provided the childcare operation with a copy of my child's most current immunication record.
 

ADMISSION REQUIREMENT:   If your child does not attend pre-kindergarten or school away from the child-card operation, one of the following must be presented when you child is admitted to the child-care operation or within one week of admission.
Please check only one option:
1.   
HEALTH-CARE PROFESSIONAL's STATEMENT: I have examined the above named child within the past year and find that he / she is able to take part in the day care program.
Health Care Professioanl's Signature
Date
 
2.   
A signed and dated copy of a health care professional's statement is attached.
3.   
Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which I adhere to or am a member of; I have attached a signed and dated affidavit stating this.
4.   
My child has been examined within the past year by a health care professional and is able to participate in the day care program. Within 12 months of admission, I will obtain a health care professional's signed statement and will submit it to the child-care operation.
Name and address of health care professional
Signature - Parent or Legal Guardian
Date
 

AUTHORIZARION FOR EMERGENCY MEDICAL ATTENTION:

In the event I cannot be reached to make arrangements for emergency medial care, I authorize the person in charge to take my child to:
Name of Physician: Address: Ph.#:
Name of Emergency Medial Care Facility: Address: Ph.#:
I give consent for the facility to secure any and all necessary emergency medical care for my child.
Signature - Parent or Legal Guardian

List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregiver's should be aware of:

 
Child daycare operations are public accomodations under the Americans with Disabilities Act (ADA), Title II. If you believe that such an operation may be practicing discrimination in violation of Title III, you may call the ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY).

Signature - Parent or Legal Guardian
Date