“FOX TRAVEL & TOURS”
Roberts Summer Camp 2013
Child’s Name: Age: Grade Entering:
Guardian’s Name: Home #
Address: Zip Code: Work #:
Employer: Cell #:
Guardian’s Name: Home #
Address: Zip Code: Work #:
Employer: Cell #:
| Weeks | Dates | Check here |
| 1 | June 3- June 7 | |
| 2 | June 10-June 14 | |
| 3 | June 17-June 21 | |
| 4 | June 24-June 28 | |
| 5 | July 8- July 12 | |
| 6 | July 15- July 19 | |
| 7 | July 22- July 26 | |
| 8 | July 29- Aug 2 | |
Emergency & Alternative Pick-Ups for my Child:
Medical Information & Permissions |
1. My child may attend a fieldtrip to the movie theater to see a children’s G or PG rated movie.
YES q NO q
2. I understand that all fieldtrips provided during summer camp hours are taken on either a Leon County School Bus or a charted bus. My child has permission to ride these buses during camp hours.
YES q NO q
3. I understand that Roberts Summer Camp often uses photos of children who attend summer camp programs for display. It is my decision that Roberts MAY USE my child’s photo during camp activities that relate to the program.
YES q NO q
4. I understand that any electronic equipment my child brings to camp with them is solely the responsibility of my child and that Roberts Elementary will not be held responsible for any lost, broken, or stolen equipment.
YES q NO q
5. My child has the following allergies ______________________________________________________________________
6. I have read and fully understand the policies outlined in the Policy Statement of the Extended Day Summer Camp. It is clear that I must have my payment in the EDEP office on or before the payment due date or a $20.00 late fee will be assessed.
YES q NO q
GUARDIAN SIGNATURE: DATE: / /