| Catch
the Creative Spirit! CASA @ Sheridan School |
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| CASA
APPLICATION 2007 |
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Please
print this page, fill it out, select the classes by first, second
and third choices, attach the deposit check and send it to: |
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| CASA
@ Sheridan School 4400 36th Street, NW Washington, DC 20008 |
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| FOR
CASA OFFICE USE ONLY |
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| Date Received: | ||
| Total Fees: | ||
| Deposit: | ||
| Check #: | ||
| Balance: | ||
| Check #: | ||
| CAMPER
INFORMATION: |
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| Last Name: | ||
| First Name: | ||
| Age: | Date of birth: | Sex: M F |
| Address: | ||
| City: | State: | Zip Code: |
| Home Phone Number: | ||
| School Currently attending: | ||
School attending in the fall 2007: |
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| Grade in the fall 2007: | ||
| Name of Person RESPONSIBLE for Aftercamp pick-up: | ||
| Phone Number: | Cell Phone: | |
| PARENT I: | ||
| Last Name: | First Name: | |
| Address: | ||
| City: | State: | Zip Code: |
| Phone Number: | Cell Phone: | |
| Work Number: | Fax: | |
| E-mail: | ||
| PARENT II: | ||
| Last Name: | First Name: | |
| Address: | ||
| City: | State: | Zip Code: |
| Phone Number: | Cell Phone: | |
| Work Number: | Fax: | |
| E-mail: | ||
| How did you hear of CASA? | ||
| If you are new to CASA, where did you go last year? | ||
| CAMPER HEALTH INFORMATION: | ||
| (To be filled out by Parent/Guardian of Camper. This must be complete signed to process application) | ||
| Additional Person to Contact in Emergency: | ||
| Relation: | ||
| Phone Number: | Cell Phone Number: | |
| Doctor's Name: | ||
| Camper Health Plan: | Policy Number: | |
| Food Allergies: | ||
| Drug Allergies: | ||
| (Please hand the CASA office a photo of your child indicating food or medication allergies) | ||
| Environmental Allergies: | ||
| Other Allergies: | ||
| Medication used for above allergies: | ||
Asthma:
 Yes No |
Medication for Asthma: | |
| Does
Camper need Epi-Pen? Yes No If yes, you MUST supply to the CASA office |
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| Does
Camper take prescription medication? Yes No (If camper will be taking medication during the summer camp day a doctor's order form with directions is needed) |
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| Please
tell us about your child's major strengths and weaknesses in terms
of personal qualities, social skills and proficiencies. Please feel
free to write separately with additional information or concerns
you have which would help us to provide the best possible summer
experience for your child. |
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| Please
list any special conditions in your child's medical history of which
we should be aware of in taking care of your child. |
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| Please summit a copy of your child's recent immunization record with the registration form and payment. | ||
| Except as stated in this application, this individual is in good health and is capable of participating in all camp activities. In case of emergency, when neither parent can be reached by phone, I give my permission to the Director or in her absence to her designee, to arrange for emergency medical treatment. | ||
| I have read the brochure and give my child permission to attend CASA. My child understands that he/she will need to follow all CASA rules. I have enclosed a non-refundable deposit of $200 per session for the core program to reserve my child's place in the program. I agree to pay the balance of tuition by May 4, 2007, or my space may be forfeited. I give permission for photos of my child and his/her artwork to be used for promotional purposes. I give permission for my child to go on camp field trips. I understand that after May 4, 2007 NO refunds will be given. | ||
| Signature
of Parent/Guardian Print Name Date _________________________________________________________________ |
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