2019 Summer Camp Elementary Application 2019 Summer Camp Elementary Application Child's Name:* First Last Child's Date of Birth:* Does your child attend Hudson Montessori School?*YesNoWill your child attend Hudson Montessori School in September?*YesNoWhich school does your child attend?*Age as of 6/24/19:*Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mother's Name* First Last Mother's Phone:*Mother's Email Address* Enter Email Confirm Email Father's Name:* First Last Father's Phone:*Father's Email Address:* Nanny/Caregiver's Name:*If Not Applicable, please input N/A First Last Nanny/Caregiver's Phone:*If not applicable, please input 999-999-9999Emergency Contact 1 Name:* First Last Emergency Contact 1 Phone:*Emergency Contact 2 Name:* First Last Emergency Contact 2 Phone:*Please list the first and last name of all Authorized Release Persons:* Authorize Release Person(s) Pictures:*Prior to uploading the picture file, please make sure the file includes the authorized release person's first and last name, as well as their relationship to the child. Drop files here or Does your child have any allergies?*YesNoPlease explain:*Does your child have any dietary restrictions?*YesNoPlease explain:*Does your child take any medications on a regular basis?*YesNoPlease explain:*Additional Comments:Summer Camp Photo/Video Waiver:Consent:*I consentI do not consentI give my permission to have my child's photo or video taken while participating in activities at Hudson Montessori School. I understand that these images may be used for projects, newsletters, our school website, social media and other Hudson Montessori School related publications, and are the sole property of the school.Summer Camp Walking Permission Slip:Consent:*I consentI do not consentDuring summer camp, children will be taking nature walks through the neighborhood and will have picnics in neighborhood parks. I give my child permission to participate in activities outside of Hudson Montessori.Hudson Montessori Parental Consent and Waiver of Liability FormPlease download the following form. Your child with NOT be permitted in the pool if the form is not signed and returned. The form may be dropped off at the 10 Regent Main Office, emailed to email@example.com or faxed to 201-516-0701. http://hudsonmontessori.net/wp-content/uploads/sites/215/2017/06/HMS-PARENTAL-CONSENT-AND-WAIVER-OF-LIABILITY.pdfImmunization & Universal Child Health RecordAll children attending summer camp must submit their Immunization and Universal Child Health Record before the first day of camp unless they were enrolled at Hudson Montessori School in the 2018-2019 school year. The child health record needs to be completed by a doctor and can be downloaded from http://www.state.nj.us/health/forms/ch-14.pdf. The two forms may be dropped off at the 10 Regent Main Office, emailed to firstname.lastname@example.org or faxed to 201-516-0701.Camp T-shirtsAll campers are required to wear a HMS Summer Camp T-shirt to camp. *Camp T-shirts from previous years may be used instead of purchasing new ones. Cost: $15.00/T-shirtNumber of T-shirts:*012345Size:*YXSYSYMYLMy child has a Hudson Montessori camp t-shirt that can be used from a previous year.Hours & SessionsBY COMPLETING AND SUBMITTING THIS SIGNED APPLICATION, AN AGREEMENT IS MADE BY THE PARENT WITH HUDSON MONTESSORI SCHOOL TO HAVE YOUR CHILD ENROLLED FOR THE ENTIRETY OF THE CAMP SESSION(S) INDICATED IN THE APPLICATION. PARENTS ARE RESPONSIBLE FOR FULL PAYMENT OF THE CAMP SESSION(S) IN WHICH THEIR CHILD IS ENROLLED. ALL PAYMENTS ARE NON-REFUNDABLE. Summer Camp Deposit Fee*A summer camp deposit in the amount of $500 is required to register your child for Hudson Montessori's summer camp. Upon submission of this application, you will receive an email with instructions for payment through our payment service provider, FACTS. I understand by submitting this application, the deposit fee must be made within 1-2 business days after receiving the account setup instructions.I AgreeSummer Camp Deposit Fee*I understand by submitting this application, the deposit fee in the amount of $500 will be scheduled for payment on my FACTs account within the next 1-2 business days.I AgreeFull Summer Camp Fee Payment*I understand that my child's registration will only be confirmed once full payment is received for summer camp. The remaining summer camp fee balance will be scheduled on Friday, June 7, 2019.I AgreePlease list the name of the parent/guardian who will make the summer camp payment.*Which session(s) are you interested in? (Press Ctrl+Mouse Click to select multiple sessions):*Session 1 (6/24-7/12)Session 2 (7/15-8/2)Session 3 (8/5-8/16)Session 1 Hours:*8:30-3:008:30-6:00Session 1 Early Drop-Off (Press Ctrl+Mouse Click to select multiple weeks):*Week 1Week 2Week 3Early Drop-Off is not needed.Session 1 After-Care (Press Ctrl+Mouse Click to select multiple weeks):*Week 1Week 2Week 3After-Care is not needed.Session 2 Hours:*8:30-3:008:30-6:00Session 2 Early Drop-Off (Press Ctrl+Mouse Click to select multiple weeks):*Week 1Week 2Week 3Early Drop-Off is not needed.Session 2 After-Care (Press Ctrl+Mouse Click to select multiple weeks):*Week 1Week 2Week 3After-Care is not needed.Session 3 Hours:*8:30-3:008:30-6:00Session 3 Early Drop-Off (Press Ctrl+Mouse Click to select multiple weeks):*Week 1Week 2Early Drop-Off is not needed.Session 3 After-Care (Press Ctrl+Mouse Click to select multiple weeks):*Week 1Week 2After-Care is not needed.Signature*Date:* This iframe contains the logic required to handle Ajax powered Gravity Forms.