Summer Camp Be A

Summer Camp ****

Child’s Name: DOB:

Child’s Name: DOB: Home Address: Phone:

Mother/Guardian Father/Guardian

Name: Name: Employer: Employer: Work Phone: Work Phone: Cell: Cell: E-mail: E-mail: Does your child have allergies? If yes, please list: Does your child have any medical condition that would necessitate a staff member to administer medication? If yes, please explain: I authorize the following individuals to sign out my child from St. Vincent de Paul Summer Camp:

Name Name Name Name Please circle the days/weeks your child will be attending this summer. June 2019

Mon Tues Wed Thurs Fri

27

Closed

28 29 30 31

3 4 5 6 7

10 11 12 13 14

17 18 19 20 21

24 25 26 27 28

**Please note week of May 27th & July 4th & July 24th – Full Week rate will be $160. *** July 2017

Mon Tues Wed Thurs Fri

1

2 3 4

CLOSED

5

CLOSED

8 9 10 11 12

15 16 17 18 19

22

23 24

CLOSED

25 26

Aug 2017

Mon Tues Wed Thurs Fri

29 30 31 1 2

5

6 7 8 9

• August 9th is the last day of Summer Camp. We will be closed August 12th-16th for cleaning. We will open August 19th for school year Extended Day.

Emergency Care

If I/we cannot be reached immediately in an emergency, I/we delegate full authority and temporary care of the child to the following local relatives, neighbors, or friends: Name: Relationship to child: Address: Phone: Name: Relationship to child: Address: Phone: In case of emergency, I/we authorize St. Vincent de Paul EDP to call the physician listed (or another if s/he cannot be reached) and follow his/her instructions: Physician: Phone: Choice of Hospital:

I/we authorize the St. Vincent EDP to call an ambulance or paramedics or fire department, and to follow instructions given. The St. Vincent EDP does not assume any responsibility for the above emergency procedures and does not assume payment for measures taken. By signing below, I/we agree to all statements given on this application Mother/Guardian Signature: Date: Father/Guardian Signature: Date:

• Please attach a non-refundable registration fee per child to this application: K-3

rd

$40

4

th

and up $60.

OFFICE USE ONLY

Date Rcvd:

Check #/Cash:

Amount Rcvd: $

Saint Vincent de Paul Parish School

DIRECT SUMMER CAMP WITHDRAWAL AUTHORIZATION FORM

Please mark all that apply. If a separate account is needed for each withdrawal, please complete separate forms Summer Camp 2019

Please ATTACH A VOIDED CHECK. (DO NOT attach a deposit slip)

New Student(s) Account No Change (use same account as school year) Name (as shown on bank account)

Address City

State Zip Home Phone Daytime Phone

Child’s Name/Grade Entering Child’s Name/Grade Entering Email Child’s Name/Grade Entering Child’s Name/Grade Entering Checking Savings Financial Institution

Transit Routing Number (9 digit bank #) Bank Account Number I authorize Saint Vincent dePaul School to automatically deduct weekly Summer Camp Tuition from the above referenced bank account. I understand this authorization will remain in effect until I provide written notice of termination in such time and in such manner as to afford Saint Vincent de Paul School a reasonable opportunity to act on it (minimum of 7 business days notice prior to effective date). I understand that it is my responsibility to notify Saint Vincent de Paul School of any change in student(s) enrollment. I understand that Saint Vincent dePaul School reserves the right to terminate this service at any time.

/ / Signature (required for validation) Date

Terms of service: Debits will be made on the Friday of each week following the student attendance unless that day falls on a weekend or other bank holiday. In the event that the Friday falls on a non-banking day, the debit will be processed on the next available business day. Saint Vincent de Paul School is not responsible for bank account charges, NSF or other bank fees, or overdrafts caused by automatic transactions. Saint Vincent dePaul School will assess a $25.00 FEE on all transactions returned for non-sufficient funds.

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