Summer Camp Application

Legal First Name    Last Name Middle Initial 

Camper Prefers to be Called Date of Birth (mm/dd/yyyy)

Gender Male Female    Age  8 9 10 11 12 13 14 15 16 17   Address 

City    State   Zip Code 

Phone    Cell Phone 

_______________________________________________________________________________________

Parent/Guardian Information

First Name       Last Name    

I prefer to be addressed as

Address     City   State  

Zip Code Home Phone    Work Phone     Ext.  

Cell Phone

Email Address   Would you like to be put on our newsletter email list?  Yes No

______________________________________________________________________________________

Applicants Information

Please select all that apply.

Autism     Frequent Ear Infection     Bleeding  or clotting disorders    Asthma

Convulsions    Diabetes    ADD/ADHD    Heart Defect or Disease    Hyper/Hypotension

Inoculations

This applicant has all immunizations that are required for school enrollment and they are current. 

Tetanus Inoculations   Date of Inoculation  _____________           Parent/Guardian Initial___________ 

Past Diseases

German Measles    Chicken Pox    Mumps    Hay Fever

Please list all serious injuries or operations below.

Allergies

Please list all allergies including medications, animal bites and stings, food and etc. in the space provided.

Current Medication

Please list medication the applicant is currently taking. ** If sending prescription medication/treatment to the camp with the applicant, please send in the original container/bottle and include the directions.

Does camper have a disability due to chronic or recurring illness. Yes  No

If yes, please describe.

Are there any special activities to be encouraged or limited by physicians advice?

Does your participant have any special needs (physical, mental or psychological)?

Physician/Hospital Information

Family Physician Name

Family Physician Phone

Preferred Hospital

Insurance Provider   Insurance Policy Number

Emergency Contact & Pick-up Information

In case of emergency, if we are unable to reach you, who should we call?

Name   Relationship to camper 

Phone number:    Work number:   Ext.

 Who is eligible to pick up your student from camp?

1. Name   Relationship    Phone 

2. Name    Relationship    Phone 

3. Name    Relationship    Phone 

Financial Aid

Financial Aid
If your student needs financial assistance to attend camp, please submit the following:

• Send in a brief statement (100 words or less) stating why you, as the parent / guardian, believe your student needs and should be eligible for financial assistance.
• Have the student write and send in a minimum of 300 words or two pages (which ever is greater) concerning why they want to attend the Todd Academy, Inc. Camp(s) they have selected, what they feel they will learn from the camp(s), what they excel at in life and / or school, and where they can improve themselves in life and / or school. We would prefer their statement be typed on the computer with the following requirements : Time New Roman, 12 pt font, Singe Spaced.

Limited financial assistance will be issued on a case-by-case basis depending on the family and student need(s). Please be prepared to receive a phone call or other form of communication concerning your request for financial assistance.
 

Please submit the student and parent statements to: director@toddacademy.com and attach the completed statements including students name and camp(s).

Promotional Agreement
 

Child's Name    Todd Academy, Inc. DOES NOT have my permission to use photographs of my student in Todd Academy, Inc. promotional material. 

PARENT / GUARDIAN AUTHORIZATION: I hereby to declare that my child is to be declared physically sound, having medical approval to participate in the activities of Todd Academy, Inc. This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed program activities except as noted. I further understand that neither Todd Academy, Inc. nor any of its paid staff or volunteer workers can be held responsible in the event of an accident. I certify that my child is amenable to discipline and free from habits or attitude, which would make him / her an undesirable participant. I have read the information in this camper packet and understand the contents thereof. Initials  

TRANSPORTATION & ACTIVITIES: I hereby give permission for my child to participate in camp activities and to travel the with Todd Academy, Inc. staff. I understand that only a licensed and qualified personnel will operate any vehicle to and from Todd Academy, Inc. Summer Camp and that there will be at least one staff member present at all times. I agree to release Todd Academy, Inc., it's officers and directors, and the Todd Academy, Inc. Camp staff from any and all claims of damages, demands and liabilities which may arise as a result of my child's participation in camp activities and travel. Initials  

EMERGENCY AUTHORIZATION: I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests, and treatment for me or my child, and in the event I am unable to communicate of cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and order injection(s) and / or anesthesia and / or surgery for me or my child as named above. I will be full responsible for any cost of such treatment, even if not covered by insurance. Initials  

PARENT / GUARDIAN PERMISSION: My initials below indicate that I have legal authority to sign-up the child name in the form and that to the best of my knowledge the information on this application is complete and accurate. I further understand that this is an application and the child's participation is contingent upon space being available in the program(s) in which I want the child to participate. I also understand that once my application is confirmed, I must complete payment(s) by the beginning of camp. All deposits to hold spot in camp must be paid immediately. Furthermore, all necessary health, security and waiver forms must be signed and on file with Todd Academy, Inc. prior to my child attending the program(s). Failure to comply with the above could result in the loss of the camp space. Initials 

Please submit this form and then select the camp selections on the form next to this one. When you have completed the selections form you can finish checking out at PayPal. You do not need a Paypal account to checkout.