ISLAMIC SOCIETY of AUGUSTA

Summer Camp 2010

June 1 – July 31
 

Enrollment Application# _______________ Date _______ / ________/________

Student’s Name ________________________________________Age ________ Date of birth ____/____/____
Gender of child: Male _____ Female_____
Address ______________________________________________________
City __________________________State_____ Zip __________

Person Responsible for Payment __________________________________

Mother’s Name ________________________________________________
Mother’s Contact Number _______________________________________
Father’s Name _________________________________________________
Father’s Contact Number ________________________________________

Name and phone number of at least two other persons to contact if parents cannot be reached
Name _________________________________________ Phone__________________________
Name _________________________________________ Phone__________________________

Person who may pick up your child other than parents

Name___________________________________Relationship___________________Phone________________
Name___________________________________Relationship___________________Phone________________
Name___________________________________Relationship___________________Phone________________

Please list names and ages of other children in the family

__________________________________________________________________________

Special Needs:
Check all meals & snacks you would like for your child: AM Snack____ Lunch_____ PM Snack____
Allergies or Food Restrictions? If yes, please list:
_________________________________________________________________________________
Prescribed Medications? If yes, please describe:
_________________________________________________________________________________
Mobility Limitations? If yes, please describe:
_________________________________________________________________________________
Other physical or mental needs requiring staff attention: If yes, please describe:
_________________________________________________________________________________
What time of day may we expect your child to arrive and to depart? This is very important in planning for
adequate staff to care for your child: (Our Hours of Operation are Mon-Thur 8:30am and 12:30pm Fri 8:30am-
1:30pm)
Mon: _________to____________
Tue: _________to_____________
Wed: _________to____________
Thur: _________to____________
Fri: __________to_____________

In case of emergency, I give my permission for my child __________________ to be taken to

______________________________________Hospital or to a physician for treatment.

Parent’s Signature _____________________________________

My child _______________________ has my permission to participate in field trips sponsored by ISA Summer
Camp. It is also understood that individual permission slips will normally be signed for each trip.
Initials_______

We at ISA Summer Camp DO NOT ALLOW ANY SORT OF MISBEHAVIOR under any circumstances

MISBEHAVIOR INCLUDES BUT IS NOT LIMITED TO:

HITTING
SLAPPING
BITING
PINCHING
PUSHING
FIGHTING (Whether playing or not)
DISRESPECT (Physically and Verbally)
BULLYING

NONE OF THESE BEHAVIORS ARE ALLOWED ON THE ISA PREMISES AT ANY TIME BY OUR
TEACHERS OR STUDENTS. The student gets three verbal warnings, before the parent/guardian is called to
pick up their child. Initials ______

You acknowledge that by signing my name I have fully read and understood the above statement. I
intend to sign my child into ISA Summer Camp. Registration fee of $10 per child is due at the time of
filling this registration form. I agree to pay $25 a week due on the first Monday of every week, and $5 per
field trip per week that my child is attending due the day before the intended field trip. Any drop in
children is $10 per day per child.

Parent’s Signature________________________________________ Date ___________________________

Director’s Signature__________________________________________________________________
Date_______________________ Enrollment Date __________________________