Camp Carden Registration - Summer 2010
(408) 626-8008 phone / (408) 626-8044 fax
www.cardendayschool.com
Child’s Name: _________________________________ Age: _____ Grade: _____
Street Address: ____________________________ Home Telephone: _____________
City: _______________________ State: _________ Zip Code:
_______________
FAMILY INFORMATION
Mother’s Name: ____________________________________________
Email Address: __________________
Work Telephone: ________________ Cell Number: _________________
Father’s Name: _____________________________________________
Work Telephone: ________________ Cell Number: _________________
Email Address: __________________
ADULTS TO CONTACT IF
PARENTS ARE UNAVAILABLE:
1. Name: _________________________________ Phone: _____________________
Address: _____________________________________ Relationship: ___________
2. Name: _________________________________ Phone: _____________________
Address: _____________________________________ Relationship: ___________
3. Name: _________________________________ Phone: _____________________
Address: _____________________________________ Relationship: ___________
PERSONS AUTHORIZED TO
PICK UP YOUR CHILD:
1. Name: _________________________________ Phone: _____________________
Address: _____________________________________ Relationship: ___________
2. Name: _________________________________ Phone: _____________________
Address: _____________________________________ Relationship: ___________
3. Name: _________________________________ Phone: _____________________
Address: _____________________________________ Relationship: __________
If your child is to be picked up by anyone who is not on
this list, you MUST notify the camp
director with a written
notice. A verbal notification will not
be accepted. Notice may be faxed to
(408)626-8044.
IN CASE OF EMERGENCY
Name of Physician: _________________________________ Phone #: ______________
Name of Dentist: __________________________________ Phone #: ______________
Health Insurance Carrier and Policy #: ________________________________________
Major illnesses or accidents student has incurred: ________________________________
______________________________________________________________________
Does your student have any of the following?
□ Allergies
□ Asthma
□ Diabetes
□ Heart Disease
□ Physical Disability
□ Rheumatic Fever
□ Other: ____________________________
If yes, please explain any care needed while at school: ____________________________
_____________________________________________________________________
Please describe any physical disabilities: ______________________________________
_____________________________________________________________________
Describe any medication or special diet: _______________________________________
_____________________________________________________________________
Describe any allergies to medications: ________________________________________
_____________________________________________________________________
May your child participate in all physical activities that will be offered in Camp Carden?
▫ Yes
▫ No
MEDICAL RELEASE
In the event of an emergency, and if all efforts to reach me have been unsuccessful, I give permission for my child to be taken to the emergency room at Santa Clara Valley Medical Center and to be treated there by the attending physician. I understand that this permission slip would accompany my child and that continued efforts would be made to reach me. I agree to assume the financial obligation incurred for such care.
Parents’/Guardians’ Signatures:______________________ ______________________
FIELD TRIP PERMISSION
I give permission for ____________________________ to participate in field trips as a part of Camp Carden.
_______________________________
Parents’/Guardians’ Signature
PHOTOGRAPHY RELEASE
I give permission for my child to be photographed during the Camp Carden program. I understand the photographs may be used for marketing and/or public relations.
_______________________________
Parents’/Guardians’ Signature
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Carden Day School Lower Campus (Pre-K - 3rd) |
Carden Day School Upper Campus(4th - 8th) |
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