Draft-Online Registration-Sumac


Welcome to our portal...Whatever blah...

	How did you hear about us? *	Referral Name: * - denotes required fields
	Family Information:
	Family Name:
	Lives With: First Name:*	Last Name: * Type:

	Home Phone: *	Cell #: Work #:
	Email:*	(Emails are kept confidential)

	Contact #2 First Name:	Last Name: Type:*

	Home Phone:	Cell #: Work #:
	Email:	(Emails are kept confidential)

	Address: *
	City: *	State: * Zip: *
	Home Phone: *
	Emergency Contact Info.: (Not Lives With:, Contact #2)
	Health Insurance Carrier:
	Security Code:*
	Test Field 2:
	:
	:
	:

Student #1 Information:

	Student's First Name: *	Last Name: *
	Student Gender:	Birth Date: * (format=mm/dd/yy)
	Transportation:
	Special Needs:
	Allergies:
	Immunization Notes:
	Skill Notes:
	Childcare 6-9am Days M-F?:
	Childcare 9-12pm Days M-F?:
	Childcare 12-3pm Days M-F?:
	Childcare 3-6pm Days M-F?:
	Student Cell Number:*
This text goes above the Class Search button Step 1: For each student: Pick either 1 class a week or 2 classes a week bundle option Step 2: Choose which classes each student will attend
	Classes
	Select Class #1:	_______________
	Select Class #2:	_______________
	Select Class #3:	_______________
	Select Class #4:	_______________
	Select Class #5:	_______________

Student #2 Information:

Show-Hide Details

	Student's First Name:	Last Name:
	Student Gender:	Birth Date: (format=mm/dd/yy)

	Transportation:
	Special Needs:
	Allergies:
	Immunization Notes:
	Skill Notes:
	Childcare 6-9am Days M-F?:
	Childcare 9-12pm Days M-F?:
	Childcare 12-3pm Days M-F?:
	Childcare 3-6pm Days M-F?:
	Student Cell Number:*
	Classes
	Select Class #1: *	_______________
	Select Class #2:	_______________
	Select Class #3:	_______________
	Select Class #4:	_______________
	Select Class #5:	_______________

Student #3 Information:

Show/Hide Details

	Student's First Name:	Last Name:
	Student Gender:	Birth Date: (format=mm/dd/yy)

	Transportation:
	Special Needs:
	Allergies:
	Immunization Notes:
	Skill Notes:
	Childcare 6-9am Days M-F?:
	Childcare 9-12pm Days M-F?:
	Childcare 12-3pm Days M-F?:
	Childcare 3-6pm Days M-F?:
	Student Cell Number:*
	Classes
	Select Class #1: *	_______________
	Select Class #2:	_______________
	Select Class #3:	_______________
	Select Class #4:	_______________
	Select Class #5:	_______________

Student #4 Information:

Show/Hide Details

	Student's First Name:	Last Name:
	Student Gender:	Birth Date: (format=mm/dd/yy)

	Transportation:
	Special Needs:
	Allergies:
	Immunization Notes:
	Skill Notes:
	Childcare 6-9am Days M-F?:
	Childcare 9-12pm Days M-F?:
	Childcare 12-3pm Days M-F?:
	Childcare 3-6pm Days M-F?:
	Student Cell Number:*
	Classes
	Select Class #1: *	_______________
	Select Class #2:	_______________
	Select Class #3:	_______________
	Select Class #4:	_______________
	Select Class #5:	_______________

Student #5 Information:

Show/Hide Details

	Student's First Name:	Last Name:
	Student Gender:	Birth Date: (format=mm/dd/yy)

	Transportation:
	Special Needs:
	Allergies:
	Immunization Notes:
	Skill Notes:
	Childcare 6-9am Days M-F?:
	Childcare 9-12pm Days M-F?:
	Childcare 12-3pm Days M-F?:
	Childcare 3-6pm Days M-F?:
	Student Cell Number:*
	Classes
	Select Class #1: *	_______________
	Select Class #2:	_______________
	Select Class #3:	_______________
	Select Class #4:	_______________
	Select Class #5:	_______________

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Please select the number of class cards (5 class card - $100, 10 class card - $160.00, 20 class card - $280, 30 class card - $360 or unlimited classes - $400) you are purchasing and post that number in the comment section at the bottom of this registration form just above the credit card verification section.

If you are enrolling in the unlimited class card, you need to only register for that class and not each individual class you plan to attend. You will be charged for the number of class cards you select and a $15.00 registration fee if you are a new student. We will have a class card ready for you when you come to your first class.

Please make sure you provide your credit card information for online registration payment.
I've read the above and agree.

Release of Liability
As the legal parent or guardian, I release and hold harmless ____________________, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, include

I've read the above and agree.

Late Payment Information
Tuition is based on a 4 week session and is due before the session starts. We can't hold your space in class until payment is received

There is a $30.00 returned check charge for any checks returned by the bank.
I've read the above and agree.

Signature Text
As the legal parent or guardian, I release and hold harmless ____________________, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control and supervision of _________________, its owners and operators or in route to or from any of said premises.
I've read the above and agree.

Medical Emergency
The undersigned gives permission to ____________________, its owners and operators to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. I hereby declare any physical/mental problems, restictions, or condition and/or declare the paricipant to be in good physical and mental health.

I request that our doctor/physician ________________ be called and that my child be transported to ______________________ hospital. Please include physicians' phone number _______________.
I've read the above and agree.

test tuition flow
FALL 2009

PLEASE NOTE THAT DISCOUNTS FOR MULTIPLE STUDENTS WITHIN A FAMILY WILL BE GIVEN UPON TUITION POSTING TO YOUR ACCOUNT. Upon registration, each student must pay a registration fee and May 2010 tuition. If you choose not to participate in EFT, you must also pay a $45 administrative fee, due with registration. All tuition and fees paid are non-refundable.

1 HR or less.......... $60 per month
1.5 HR.....................$80
2 ........................$90
2.5 HR.....................$100

3 HR........................$115
3.5 HR.....................$125

4 HR........................$130
4.5 HR.....................$145

5 HR........................$150
5.5 HR.................... $155

Unlimited................$165

I've read the above and agree.

like on jeffs

I understand the Director reserves the right to dismiss any camper whose behavior/attitude is disruptive or detrimental to the welfare of the camp. No refund will be given in the event of dismissal. It is the parent's responsibility to arrange transportation for early dismissal.
I authorize the use of my child's photograph in any camp publications (i.e. website, brochure, etc.).
I am aware that the $50 non-refundable deposit guarantees only the week for which my child was accepted; it does not guarantee a spot if he/she elects to change into a different week at a later date.
If my child is not at camp by 5:30 PM on Sunday of his/her selected week, then, at the Camp Director's discretion, my child may be deemed to have forfeited his/her space, and the space will be offered to another camper due to the waiting list that we have in many weeks.
Any bounced checks will incur a $20 processing fee.

I've read the above and agree.

Enter your Full Name:




	Comments:


	e-Payment Schedule Pref:*
	Please choose ONE of the following Payment methods: Credit Card or Bank Draft

	Credit Card Verification:

	Name as it appears on card:
	Card Type:	Card Number:
	Card Expiration Month:	Exp Year:

	eCheck/Bank Draft:
	Bank Name:
	Bank Routing Number:	(9-digit number)
	Your Account Name:	(Your name on your bank statement)
	Your Account Type:	Account Number:

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