SUMMER BREEZE REGISTRATION FORM

STUDENT’S NAME BIRTH DATE AGE GENDER

STUDENT’S ADDRESS APT# ZIP

PARENT 1’S NAME CELL NUMBER WORK NUMBER

PARENT 2’S NAME CELL NUMBER WORK NUMBER

PARENT 1 EMAIL PARENT 2 EMAIL

PEDIATRICIAN CONTACT NUMBER

EMERGENCY CONTACT NAME (BESIDES THE PARENTS OR CAREGIVER) EMERGENCY CONTACT NUMBER

CAREGIVER’S NAME CONTACT NUMBER

IS YOUR CHILD RECEIVING SERVICES? □ YES □ NO

IF YES, WILL A SEIT ATTEND CAMP WITH YOUR CHILD? □ YES □ NO IN ADDITION TO PARENTS AND CAREGIVER, THE FOLLOWING HAVE PERMISSION TO PICK UP MY CHILD

1._______________________________________________ CONTACT NUMBER____________________________

2. _______________________________________________ CONTACT NUMBER____________________________

3. _______________________________________________ CONTACT NUMBER____________________________

CAMP REGISTRATION Please check next to the camp group you would like to place your child in

2.6-3 YEARS OLD□ TUESDAY, WEDNESDAY, THURSDAY 9AM – 12PM (Non-separated, full 8 weeks)

□ MONDAY THRU FRIDAY 9AM – 12PM (Fully separated proof required, potty-trained optional)

3-3.11 YEARS OLD □ HALF DAY MONDAY THRU FRIDAY 9AM – 12PM

□ FULL DAY 9AM – 2PM MON-THURS 9AM – 12PM FRI.

□ EXTENDED DAY 9AM – 3PM MON-THURS 9AM – 12PM FRI.

4-4.11 YEARS OLD □ FULL DAY 9AM – 2PM MON-THURS 9AM – 12PM FRI.

□ EXTENDED DAY 9AM – 3PM MON-THURS 9AM – 12PM FRI

PLEASE SELECT THE WEEKS YOU ARE ENROLLING IN. (Non-separated group must enroll for the full 8 weeks. Older groups must enroll in two consecutive weeks to begin. Additional weeks based on availability) □ WEEK 1 JUNE 19TH □ WEEK 2 JUNE 26TH □ WEEK 3 JULY 3RD □ WEEK 4 JULY 10TH □ WEEK 5 JULY 17TH □ WEEK 6 JULY 24TH □ WEEK 7 JULY 31ST □ WEEK 8 AUGUST 7TH

SUMMER BREEZE REGISTRATION FORM

SUMMER BREEZE

STUDENT PROFILE

SUMMER BREEZE DAY CAMP 1520 YORK AVENUE, NEW YORK, NY 10028*TEL: (2120 861-7732* FAX: (212) 861-8901

Camper Name: ___________________________________________________________________

Nickname: _______________________________________________________________________

Address: ________________________________________________________________________

City/State: _________________________________ Zip: ___________________________

Date of Birth: ____________________________ Age: ________ Gender: M F

Parent 1: __________________________________________________________________

Parent 1 Cell Phone: ______________________ Work Phone: ___________________

Parent 2: ____________________________________________________________________

Parent 2 Cell Phone: ______________________ Work Phone: _____________________

Email Address: ____________________________ _________________________________

Home Phone: ______________________________

PARENTS COMMENTS

Has your child been to camp before? Yes_____ No_____

If yes, which one? __________________________________________________________________

What school does your child attend? ___________________________________________

Does your child have any special fears (dogs, the dark, heights or others)?

___________________________________________________________________________________

Did your child have any special difficulties in school or at home this year?

Yes____ No ____

Is your child receiving services? Yes ___ No___

If yes please explain:

__________________________________________________________________________

What words best describe your child (easy, going, shy, outgoing, etc.)

___________________________________________________________________________________

TURN OVER

SUMMER BREEZE

STUDENT PROFILE

SUMMER BREEZE DAY CAMP 1520 YORK AVENUE, NEW YORK, NY 10028*TEL: (2120 861-7732* FAX: (212) 861-8901

How does your child handle differences with his/her peers? _______________________________

____________________________________________________________________________________

How does your child like to be comforted? _________ ______________________________________

_____________________________________________________________________________________

Additional comments/information: _______________________________________________________

_____________________________________________________________________________________

MEDICAL INFORMATION

Does your child have any food allergies? Yes___ No___

If yes please explain: ____________________________________________________________________

Does this require an Epipen? Yes ____ No____

Does your child have any other allergies? Yes____ No ____

Does your child have asthma? Yes____ No____

If yes, please fill out this section.

What brings on an attack/frequency? (cold, weather, emotionally upset,etc.)

_____________________________________________________________________________________

Medication/Dosage and frequency: ________________________________________________________

Does your child have any other medical conditions that we should know about?

Please explain: ___________________________________________________________________________________

___________________________________________________________________________________

Please list any medications that your child takes: ______________________________________________

______________________________________________

______________________________________________

SUMMER BREEZE

STUDENT PROFILE

SUMMER BREEZE DAY CAMP 1520 YORK AVENUE, NEW YORK, NY 10028*TEL: (2120 861-7732* FAX: (212) 861-8901

EMERGENCY INFORMATION

What is the best way to reach you in the event of an emergency?

Phone: __________________________ Email: ________________________

Child’s Physician: __________________________ Phone: ______________________

IF PARENTS CANNOT BE REACHED, PLEASE LIST 3 EMERGENCY CONTACTS:

Name: ________________________________ Relationship: ___________________

Daytime Phone: ______________________ Cell phone: _____________________

Name: _______________________________ Relationship: ___________________

Daytime Phone: ______________________ Cell Phone: _____________________

Name: ________________________________ Relationship: ___________________

Daytime Phone: ________________________ Cell Phone: _____________________

CHILD RELEASE INFORMATION

PLEASE LIST ALL PEOPLE INCLUDING YOURSELVES AND/OR SPOUSES, CAREGIVERS, ETC.

Name: ______________________________ Phone: __________________________

Name: _______________________________ Phone: __________________________

Name: _______________________________ Phone: __________________________

Name: _______________________________ Phone: __________________________

Name: _______________________________ Phone: __________________________

*IF THIS INFORMATION CHANGES, SUMMER BREEZE MUST BE NOTIFIED IN WRITING. YOUR CHILD WILL NOT BE RELEASED TO ANYONE NOT ON THIS LIST