Registration
2005
Address______________________________________________________
Phone______________________________
Parent Name(s)_____________________________________
Child Birthdate____________________________
Registering for (circle choice): June 20-24 August 1-5
Fairy Tale Theater Beach Party
Release Information/Emergency Contact (to whom may your child be released):
Name____________________________relation_________________phone__________
Name____________________________relation_________________phone__________
Name____________________________relation_________________phone__________
Emergency Information:
Physician________________________________________Phone__________________
Address________________________________________________
Health Insurance Company_______________________________Phone______________
Emergency Treatment: In the event of an illness or accident that requires immediate medical
attention and the parent/guardian cannot be present, I give permission for Discovery Corner personnel
to authorize treatment. I will not hold the program, the personnel, or the medical personnel responsible.
This is done with the understanding that every attempt will have been made to contact the parent/
guardian, the child's physician, and the other emergency contacts listed above.
Parent Signature_____________________________________Date_______________
I give permission for my child, _______________________________ to ride in a car with summer day camp staff or another parent assisting with the transportation during any Discovery Corner Preschool day camp field trip activities. I understand that I must provide my child's car seat in order for him/her to participate in any activities off of the preschool property.
Parent Signature__________________________________________
If your child has any allergies, please list them below:
______________________________________________________________
______________________________________________________________
______________________________________________________________
The $80 /week camp cost covers fees, snacks, supplies, and activities, and is due upon registration. The cost is non-refundable unless a session is cancelled by
Discovery Corner Preschool.
Discovery Corner Preschool
29 E. Walnut St.
Lancaster, PA 17602
