Summer 2009 Registration

How did you hear about PIM’s Student Development Camp? _______________________________________
I hereby enroll__________________________________________ subject to the conditions below.
Address______________________________________________________ Date of Birth________________
City____________________________________ State _______________ Zip Code ____________
Sex______________ School Grade in August, 2009 ______________
Parent #1 name ______________________________ Parent #2 name_______________________________
Email__________________________________________ Home Phone ______________________________
Cell Phone #1_______________________Cell Phone #2_______________________
Visa__ Mastercard ___ card number ________________________________________ exp. date___________
CVC code _______________ Please Charge My Account $____________________
Card Holder Signature_______________________________________
Enclosed With This Registration Form Is A Check In The Amount Of $_________________________________

PIM’s $60 per week- 2wk minimum – must be entering 6th grade in August 2009 or repeating 5th grade. $25 registration fee will
also be assessed per applicant. At least 1 week notice must be given to prior to withdrawal from the camp.
Please check your choice of sessions.
__ June 1-June3 __ June 8-June 10 __ June 15-June 17 __ June 22-June 24 __ June 29-July 1
__ July 6- July 8 __ July 13- July 15 __ July 20- July 22

This fee includes all the regular camp registration, program of instruction, supervision, camp-approved sponsored group expenses,
and transportation to and from camp-sponsored activities. Students must provide their own lunch due to individual dietary
needs. The tuition fee should cover all camp expenses barring extraordinary personal expenditures. In consideration of the
camper’s enrollment and the payment of the appropriate fees, camp agrees to reserve a place and to hire instructors. The camp’s
planning, hiring, promotion, and expenses are directly determined by the number of participants. The seasonal nature of summer
camping precludes any tuition rebate/reduction/allowance for camper’s late arrival/early withdrawal/non arrival/dismissal of cause.

If it is necessary to obtain off camp medical/surgical/dental services for the camper, the parent shall pay such expenses. Authority
is granted without limitation to the camp in all medical matters to hospitalize/treat/order injection/anesthesia/surgery for the
camper. The parent is responsible for all pre-existing medical conditions, out of camp medical/
surgical/hospital/pharmaceutical/allergy expenses and for providing adequate quantities of necessary medications and allergy
serums to camp in a pharmacy container with doctor’s instructions.

Camp is not responsible for damage/loss/clothing/personal effects/personal equipment used during the camper’s day. The camp
specifically advises campers not to bring jewelry/cash/valuables to camp. During the camp season, the camper and his/her
parents agree to abide by the camp rules and regulations for the health/safety/welfare of the campers and camp community.
The camp is appointed to serve in loco parentis. When deemed necessary by the camp, via the public carrier.
Smoking/possession of or use of tobacco/narcotics/liquor/ or other intoxicant or non-prescription drug on/off the camp grounds is
expressly forbidden. Camper may not leave camp grounds without the direct permission of the camp director. Violations of these
rules or other reasonable regulations will result in dismissal from camp without tuition rebate. The camp reserves the right to
dismiss any camper whose conduct is unsatisfactory or inimical to the camps best interest without tuition rebate.

We also suggest that sturdy walking shoes be worn, and that no sandals or flip flops be worn when attending or visiting camp.
Failure to follow these instructions will increase the risk of injury.
The camp program may include public performances and permission is hereby given for the camper to take part in such
performances on/off camp grounds without compensation. The camp may use photographs/ statements/ articles/ names/ music/
art/ films/ video tape of/ by camper in promoting camp/ camp related activities/ publication/ advertising/ exhibitions.
The parent represents that he/she has full authority to enroll the camper to authorize participation in activities/medical care and to
contract with PIM to serve your child during the duration of his or her participation in the camp. This contract constitutes the full
understanding of the parties and cannot be modified except in writing signed by the parities.

Enclosed with the agreement is $85 (registration fee and 1st week’s tuition). Applications and initial enrollment fees must
be paid and received by May 15th to guarantee a participation space. There is a 2 week minimum participant to support
participant continuity and social development.

No refunds will be made for a partial week’s participation. Tuition must be paid by the Wednesday of the week preceding
the attendance week. Any outstanding balance precludes admission to camp.

Dated_______________________ Parent/Guardian_____________________________________________
 Transportation Pick-up Release Form
Camper's Name: ______________________________________________________________________________
Last Name, First Name Middle Initial

Transportation Release Form In order to provide the safest possible program for your children, we
are asking each parent or guardian to list on this card those people that will be picking your child up
from camp.
Thank you in advance for helping us keep all of our children safe.

My child, _________________________________________, will be going home from camp with

__________________________________________ his/her _______________________________.

(Name of person transporting child) (Relationship to child)

If changes happen between the time this form is signed and the end of camp, the only other person
that may transport my child is:
____________________________________________, _________________________________
(Name of person transporting the child) (Relationship to child)

____________________________________________, _________________________________
(Name of person transporting the child) (Relationship to child)

For staff use only:

Date: Time: Child released to: (Relationship) Signature:

 Medical Release Form

Prescription and Non-Prescription Drugs

Child's Name__________________________________________ Birth date_____/_____/_____ Age (as 6/09) _____________

For the health and safety of children, we follow the Georgia state guidelines for the storage and
administration of all medications that are brought to camp (outlined below). This completed and signed
form must accompany the medication your child brings to PIM’s camp. This includes all prescription
drugs, non-prescription drugs, over-the-counter medicines, vitamins, inhalers, medicated creams, herbal
remedies, etc.

Medication Information
Be specific with the complete directions, including the preferred time of administration.
Please note: If your child arrives with medication and the Medication Form does not accompany the
medication or is incomplete, the medications will be held until the parent or guardian is contacted by
phone.

I consent to have the Camp administer the following medication(s):

Medication Name Dosage Time Given
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
My child takes this medication to treat______________________________________________
___________________________________________________________________
I do_____ do not _____ give permission for my son/daughter to self-administer his/her INHALER at
camp if the nurse feels it is safe and appropriate.
I do_____ do not _____ give permission to the nurse to share information relevant to the prescribed
medication administration as she determines appropriate for my child’s health and safety.

Medication prescribed for campers shall be kept in original containers bearing the pharmacy label, which shows
the date filling, the prescribing practitioner, the name of the prescribed medication, directions for use and
cautionary statements, if any, contained in such prescription or required by law, and if tablets or capsules, the
number in the container. All over the counter medications for campers shall be kept in original containers
containing the original label, which shall include directions for use.

Medication prescriptions for campers brought from home shall only be administered if it is from the original
container, and there is a written permission from the parent/guardian.

When no longer needed, medications shall be returned to a parent or guardian whenever possible. If the
medication cannot be returned, it shall be destroyed.

Physicians Name _______________________________________ Phone # _____________________

Parent Signature __________________________________________ Date ______________________

Every attempt will be made to contact the parent or guardian of the student prior to any unusual medical treatment. The undersigned parent
or guardian of the student agrees that in the event of emergency illness or accident that a licensed M.D. shall be authorized to administer
medical or surgical treatment deemed necessary for the treatment of the student. NOTICE: THIS FORM MUST BE PRESENTED PRIOR
TO ADMISSION TO CAMP.
 Health History Form
Child’s Name __________________________________ Date of Birth ________________

Address _________________________________________________________________

City ____________________________________ State ___________ Zip ____________

Home Phone _________________________

Mother’s Name ___________________________ Work/Cell Phone __________________

Father’s Name _____________________________ Work/Cell Phone _________________

Immunization Records. This section must be filled out with accurate dates!
DPT: 2 month 4 month 6 months 18 months 5 year booster
______ ______ ______ ________ _________
Polio: 2 month 4 month 6 months 18 months 5 year booster
______ ______ ______ ________ _________
MMR shot _______, or Measles ______, Mumps ______, Rubella ______
Does your child wear glasses? ___________ Contact lenses? ___________
Indicate which of these diseases your child has had:
Chicken Pox ____ German Measles ____ Strep Throat ____ Bronchitis _____
Rheumatic Fever ____ Pneumonia _____Whooping Cough ____
Chronic Ear Infections ____ Mumps ____ Measles ____ Hepatitis ____ Mononucleosis ___
Other Serious Illness _________________________ Injuries _______________________
Operation/Surgery (please be specific) _________________________________________
Does your child have allergies? ________ To what? ______________________________
Does your child take prescription medication? _________ If yes, what? _______________
________________________________________________________________________
Does medication need to be administered during the camp day? _____________________
Does your child have asthma? _________ Is an inhaler used? ______________________
Does your child have ADD? ________________ Hyperactivity? ____________________
Please tell us anything else we should know about your child.
________________________________________________________________________
________________________________________________________________________

Physicians Name _____________________________ Phone # _____________________

Parent Signature ___________________________________ Date ___________________

Every attempt will be made to contact the parent or guardian of the student prior to any unusual medical treatment. The undersigned parent
or guardian of the student agrees that in the event of emergency illness or accident that a licensed M.D. shall be authorized to administer
medical or surgical treatment deemed necessary for the treatment of the student. NOTICE: THIS FORM MUST BE PRESENTED PRIOR
TO ADMISSION TO CAMP.
 CAMPER QUESTIONNAIRE
Camper's Name: _____________________________________________________________________________
Last Name, First Name Middle Initial

Grade Entering the 2009-2010 school year: ___________________

By providing honest input concerning your campers emotional, physical, and social needs you help us ensure that he/she has
the best summer ever. Forms are confidential and are reviewed by staff working with your child. Please complete page one of
the Camper Questionnaire and please work with your camper to complete the camper section on the back. Please use
additional paper if necessary. Please provide a copy of your child’s most current IEP. This will better enable us to provide
both the academic, behavioral, and emotional support that your child may need.

Pertinent information regarding child: (i.e. parental status, major life changes, family members living elsewhere,
new siblings, etc.) __________________________________________________________________
_____________________________________________________________________
Does your camper have any concerns regarding camp? Please describe: ____________________________________
_____________________________________________________________________
Do you, as parents or guardians, have any concerns regarding camp? Please describe: ______________________
_____________________________________________________________________
_____________________________________________________________________
Does your camper have any learning or physical limitations? Please describe: _________________________
_____________________________________________________________________
_____________________________________________________________________
Is your camper highly competitive? _______________________________________________________
_____________________________________________________________________
What have you found to be the most effective form of behavior management? _________________________
_____________________________________________________________________
What do you most want out of camp for your child? ___________________________________________
_____________________________________________________________________
_____________________________________________________________________
How may we enhance your child’s experience at camp? ________________________________________
_____________________________________________________________________
_____________________________________________________________________
Is there anything else you would like to share? _________________________________________
_____________________________________________________________________
What is a favorite reinforcement for your child? _____________________________________________________
CAMPER'S SECTION (Ask Your Camper)

Camper's Name: _____________________________________________________________________________

Last Name, First Name Middle Initial

Please spend a few moments with your camper and ask him/her to share answers to these questions. Older
campers may complete this form by themselves.

What would you like other campers and staff to call you? _______________________________________________

What three things do you most want to accomplish while you are at camp?
1. ________________________________________________________________________________________________

2. ________________________________________________________________________________________________

3. ________________________________________________________________________________________________

Are there any things that concern you about coming to camp? ___________________________________________

__________________________________________________________________________________________________

What are your hobbies/interests? ____________________________________________________________________

Do you have any special talents? ____________________________________________________________________

__________________________________________________________________________________________________

While you won't meet your counselors until you get to camp, if you had a question to ask them now, what would
that be? ______________________________________________________________
____________________________________________________________________
Because we would like to know you better, is there anything else you'd like to share? _______________________

__________________________________________________________________________________________________

Thanks for taking time to fill this out! Your information will help us better serve your child.
Please return this form by May 15, 2009 to:

Practice In Motion, Inc’s Day Camp

1048 Winterglen Way, Suite #100
Austell, GA 30168

Please provide a copy of your child’s most recent IEP.