2019 Summer Camp Registration

Please complete a registration form for EACH child attending our Summer Camp Program.

Camper's Name *
Camper's Name
Camper's Date of Birth *
Camper's Date of Birth
What grade will the camper be entering next school year.
All sizes are children size.
Parent's or Guardian's Name *
Parent's or Guardian's Name
Home Phone
Home Phone
Cell Phone *
Cell Phone
Primary Address *
Primary Address
By Phone or By Email
Planned Drop-off Time
Planned Drop-off Time
Planned Pick-up Time
Planned Pick-up Time
I give my consent for my child to be transported and supervised by Southlake Tutoring Academy employees: *
Click all that apply.
I give consent for my child to participate in the following Water activities: *
If yes, you will be required to fill out an emergency allergy plan at the office and supply Southlake Tutoring Academy with any medication.
Emergency Contact #1 *
Emergency Contact #1
Emergency Contact #1 Phone Number *
Emergency Contact #1 Phone Number
Emergency Contact #2 *
Emergency Contact #2
Emergency Contact #2 Phone Number *
Emergency Contact #2 Phone Number
In case of Emergency
Physician's Phone Number *
Physician's Phone Number
On behalf of my minor child (student named on this application), I hereby give permission for my child to participate in the Southlake Tutoring Academy (STA) Camps activities, which may include, but are not limited to: games, experiments, exercise, aquatic activities, and outdoor activities. I acknowledge that my child’s participation in these activities is wholly voluntary Acknowledgement of Risk: I hereby warrant that both me and my child are familiar with the risks associated with participation in the STA camps and agree to accept any and all inherent risks. Hold Harmless I hereby release, absolve, indemnify, and hold blameless and harmless and release STA, its officers, directors, employees, contracted employees, independent contractors, instructors, agents, organizers, and volunteers of any and all liability for damage, injury, or expense of any kind arising out of or connected with my child’s participation in STA Camp. Child Will Abide By Rules and Regulations: I have instructed my child to cooperate and comply with all reasonable directions and instructions received from camp staff. I have reviewed the Camp Rules, Expectations, and Consequences outlined in the camp preparation package with my child. I understand that any violation of camp rules will result in consequences, and ultimately dismissal from camp. I understand that if my child is dismissed from the camp, I will not receive a refund for any unused portion of the pre-paid camp fee. Commitment to Being Available: I commit to being available during camp hours (9am – 4pm) to answer a phone call from STA and its staff. I have provided a phone number to STA where I can be reached at any time during camp hours. I also commit to being available or making arrangements for my child to be picked up for any reason and at any time Consent to Administer Non-Emergency First Aid: I understand and acknowledge that occasionally a non-emergency may develop which necessitates the administration of non-emergency First Aid to my child. Therefore, in the event of non-emergency injury or illness which necessitates the administration of nonemergency First Aid, I hereby authorize STA and its staff in charge of the STA Camps to administer any necessary non-emergency First Aid. Non-emergency First Aid treatment may include, but is not limited to: cleaning, applying anti-biotic ointment to, and bandaging cuts or abrasions; removal of ticks and splinters; and applying an ice-pack to bites, stings, or an injury. The following substances may be used in the administration of non-emergency First Aid: water, ice pack, ACE bandage, antibacterial soap, alcohol swabs, anti-biotic ointment, and band-aids. No oral medication will be administered unless authorized and directed by the child’s parent/guardian. I understand that if I do not consent to the administration of non-emergency First Aid or to the administration of any of the substances listed above, I will give written notification to STA no later than seven business days before the camp session begins. Consent to Administer Emergency First Aid: In the unlikely event of a life- or limb-threatening emergency, I give consent to STA and its staff to administer emergency First Aid as a first response until more advanced medical care is available. I understand that STA and its staff will use their best judgment, act in good faith, and will treat with the intention of not causing further harm. Consent to Arrange Emergency Treatment: I understand and acknowledge that on rare occasions an emergency may develop which necessitates the administration of medical care, dental care, hospitalization, or surgery to my child. Therefore, in event of injury or illness to my child which necessitates emergency medical or dental care, I hereby authorize STA and its staff in charge of the STA Camps to arrange any necessary emergency treatment including the administration of anesthetics and surgery to my child. I also understand that a parent/guardian will be contacted at the earliest possible moment in the event of an emergency relating to my child. Medical, Dental, Health, and Insurance Responsibilities: I understand and acknowledge that STA cannot assume responsibility for determining the medical, dental, or health condition of my child. Therefore, I have consulted with a medical doctor and/or dentist, as I have deemed necessary, with regards to my child’s individual medical or dental issues or needs, and find my child physically and mentally fit to participate in the STA Camps. If my child is required to receive medical, dental, or hospital services during camp, I am aware that STA cannot and does not assume legal responsibility for payment of such costs; rather, I hereby assure STA that I have assumed all risk and responsibility thereof and that my child has the necessary insurance to meet any and all needs for payment of these services during the STA Camps
I understand that as part of our child’s participation in STA Camps, photos, videos, electronic images, audio recordings and quotations of my daughter/son may be taken for use in publications and reports about the program.