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Summer 2009 Registration
How did you hear about PIM’s Student Development Camp? _______________________________________ I hereby enroll__________________________________________ subject to the conditions below.Address______________________________________________________ Date of Birth________________ City____________________________________ State _______________ Zip Code ____________ Sex______________ School Grade in August, 2009 ______________ Parent #1 name ______________________________ Parent #2 name_______________________________ Email__________________________________________ Home Phone ______________________________ Cell Phone #1_______________________Cell Phone #2_______________________ Visa__ Mastercard ___ card number ________________________________________ exp. date___________ CVC code _______________ Please Charge My Account $____________________ Card Holder Signature_______________________________________ Enclosed With This Registration Form Is A Check In The Amount Of $_________________________________ 
PIM’s $60 per week- 2wk minimum – must be entering 6
th
grade in August 2009 or repeating 5
th
grade. $25 registration fee willalso be assessed per applicant. At least 1 week notice must be given to prior to withdrawal from the camp.Please check your choice of sessions.
 __ June 1-June3 __ June 8-June 10 __ June 15-June 17 __ June 22-June 24 __ June 29-July 1 __ July 6- July 8 __ July 13- July 15 __ July 20- July 22
This fee includes all the regular camp registration, program of instruction, supervision, camp-approved sponsored group expenses,and transportation to and from camp-sponsored activities.
Students must provide their own lunch due to individual dietaryneeds.
The tuition fee should cover all camp expenses barring extraordinary personal expenditures. In consideration of thecamper’s enrollment and the payment of the appropriate fees, camp agrees to reserve a place and to hire instructors. The camp’splanning, hiring, promotion, and expenses are directly determined by the number of participants. The seasonal nature of summercamping precludes any tuition rebate/reduction/allowance for camper’s late arrival/early withdrawal/non arrival/dismissal of cause
.
 If it is necessary to obtain off camp medical/surgical/dental services for the camper, the parent shall pay such expenses. Authorityis granted without limitation to the camp in all medical matters to hospitalize/treat/order injection/anesthesia/surgery for thecamper. The parent is responsible for all pre-existing medical conditions, out of camp medical/ surgical/hospital/pharmaceutical/allergy expenses and for providing adequate quantities of necessary medications and allergyserums to camp in a pharmacy container with doctor’s instructions.Camp is not responsible for damage/loss/clothing/personal effects/personal equipment used during the camper’s day. The campspecifically advises campers not to bring jewelry/cash/valuables to camp. During the camp season, the camper and his/herparents agree to abide by the camp rules and regulations for the health/safety/welfare of the campers and camp community.The camp is appointed to serve in loco parentis. When deemed necessary by the camp, via the public carrier.Smoking/possession of or use of tobacco/narcotics/liquor/ or other intoxicant or non-prescription drug on/off the camp grounds isexpressly forbidden. Camper may not leave camp grounds without the direct permission of the camp director. Violations of theserules or other reasonable regulations will result in dismissal from camp without tuition rebate. The camp reserves the right todismiss any camper whose conduct is unsatisfactory or inimical to the camps best interest without tuition rebate.We also suggest that sturdy walking shoes be worn, and that no sandals or flip flops be worn when attending or visiting camp.Failure to follow these instructions will increase the risk of injury.The camp program may include public performances and permission is hereby given for the camper to take part in suchperformances on/off camp grounds without compensation. The camp may use photographs/ statements/ articles/ names/ music/ art/ films/ video tape of/ by camper in promoting camp/ camp related activities/ publication/ advertising/ exhibitions.The parent represents that he/she has full authority to enroll the camper to authorize participation in activities/medical care and tocontract with PIM to serve your child during the duration of his or her participation in the camp. This contract constitutes the fullunderstanding of the parties and cannot be modified except in writing signed by the parities.
Enclosed with the agreement is $85 (registration fee and 1st week’s tuition). Applications and initial enrollment fees mustbe paid and received by May 15
th
to guarantee a participation space. There is a 2 week minimum participant to supportparticipant continuity and social development.No refunds will be made for a partial week’s participation. Tuition must be paid by the Wednesday of the week precedingthe attendance week. Any outstanding balance precludes admission to camp.
 
Dated_______________________ Parent/Guardian_____________________________________________ 
 
 
 
Transportation Pick-up Release Form
Camper's Name: ______________________________________________________________________________ 
Last Name, First Name Middle Initial
Transportation Release Form
In order to provide the safest possible program for your children, weare asking each parent or guardian to list on this card those people that will be picking your child upfrom camp.
Thank you in advance for helping us keep all of our children safe.
My child, _________________________________________, will be going home from camp with__________________________________________ his/her _______________________________.(Name of person transporting child) (Relationship to child)If changes happen between the time this form is signed and the end of camp, the only other personthat may transport my child is:____________________________________________, _________________________________(Name of person transporting the child) (Relationship to child)____________________________________________, _________________________________(Name of person transporting the child) (Relationship to child)
For staff use only:Date: Time: Child released to: (Relationship) Signature:
 
 
Every attempt will be made to contact the parent or guardian of the student prior to any unusual medical treatment. The undersigned parentor guardian of the student agrees that in the event of emergency illness or accident that a licensed M.D. shall be authorized to administermedical or surgical treatment deemed necessary for the treatment of the student.
NOTICE: THIS FORM MUST BE PRESENTED PRIORTO ADMISSION TO CAMP.
 
Medical Release Form
Prescription and Non-Prescription Drugs
Child's Name
__________________________________________
Birth date
_____/_____/_____
Age (as 6/09) ___ 
__________
For the health and safety of children, we follow the Georgia state guidelines for the storage andadministration of all medications that are brought to camp (outlined below). This completed and signedform must accompany the medication your child brings to PIM’s camp. This includes all prescriptiondrugs, non-prescription drugs, over-the-counter medicines, vitamins, inhalers, medicated creams, herbalremedies, etc.
Medication InformationBe specific with the complete directions, including the preferred time of administration.
Please note: If your child arrives with medication and the Medication Form does not accompany themedication or is incomplete, the medications will be held until the parent or guardian is contacted byphone.I consent to have the Camp administer the following
medication(s):
Medication Name Dosage Time Given
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
My child takes this medication to treat
_________________________________________________________________________________________________________________
I do_____ do not _____ give permission for my son/daughter to self-administer his/her INHALER atcamp if the nurse feels it is safe and appropriate.I do_____ do not _____ give permission to the nurse to share information relevant to the prescribedmedication administration as she determines appropriate for my child’s health and safety.
Medication prescribed for campers shall be kept in original containers bearing the pharmacy label, which showsthe date filling, the prescribing practitioner, the name of the prescribed medication, directions for use andcautionary statements, if any, contained in such prescription or required by law, and if tablets or capsules, thenumber in the container. All over the counter medications for campers shall be kept in original containerscontaining the original label, which shall include directions for use.Medication prescriptions for campers brought from home shall only be administered if it is from the originalcontainer, and there is a written permission from the parent/guardian.When no longer needed, medications shall be returned to a parent or guardian whenever possible. If themedication cannot be returned, it shall be destroyed.
Physicians Name _______________________________________ Phone # _____________________ Parent Signature __________________________________________ Date ______________________ 
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