Summer Camp Enrollment Summer Camp Enrollment Please fill out the following enrollment application and the Center Director will contact you shortly. Date Enrolled(Required) MM slash DD slash YYYY Days & Hours Care is Needed(Required) Please list what days your child will be attending and the approximate times they will arrive and leave. Center Location(Required)Please choose 1st choiceKenova – 725 Chestnut St Kenova, WV 25530Lavalette – 5185 Rt 152 Lavalette, WV 25535Huntington – 418 Bridge St Huntington, WV 25702Westmoreland – 3603 Piedmont Rd Huntington, WV 25704Buffalo – 330 Buffalo Creek Rd Kenova, WV 25530Ceredo – 111 4th St E Ceredo, WV 25507Child's Full Name(Required) Full Name Complete Address including Zip Code(Required) Complete Address including Zip Code Guardian #1 Full Name(Required) Full Name Phone #1(Required)Phone #2Guardian #1's Complete Address including Zip Code(Required) Complete Address including Zip Code Guardian #2 Full Name(Required) Full Name Phone #1(Required)Phone #2Guardian #2's Complete Address Including Zip Code(Required) Complete Address including Zip Code Emergency Contact #1 Name(Required) Full Name Phone #1(Required)Phone #2Complete Address including Zip Code(Required) Complete Address Including Zip Code Relationship to Child(Required)Choose OneGrandparentAunt/UncleSiblingFamily FriendEmergency Contact #2 Full Name(Required) Full Name Phone #1(Required)Phone #2Complete Address including Zip Code(Required) Complete Address Including Zip Code Relationship to Child(Required)Choose OneGrandparentAunt/UncleSiblingFamily FriendIs there a court order for custody?(Required)Please choose oneYes (a copy must be provided to center)NoList any people NOT ALLOWED to pick up childPhysician Name(Required) Full Name Complete Address including Zip Code(Required) Complete Address including Zip Code Phone(Required)Dentist's Name(Required) Full Name Complete Address including Zip Code(Required) Complete Address including Zip Code Phone(Required)Hospital(Required) Full Name Complete Address including Zip Code(Required) Complete Address including Zip Code Phone(Required)Child's Health Insurance(Required)ID#(Required)Name on Card(Required)Please list any special conditions, disabilities, allergies, dietary needs or medical conditions(Required)Consent(Required) I give authorization for staff to act in emergency.As parent/guardian, I authorize Playmates staff to administer first aid and, if necessary, transport my child for emergency medical care. I understand I am responsible for any charges not covered by insurance. Staff will attempt to contact me immediately. If I am unavailable, I consent for listed emergency contacts to act on my behalf. If no one can be reached, I authorize staff to seek emergency medical evaluation and treatment as needed.Consent I give permission for use of photograph, audio and video tape.I give Playmates Preschool & Child Development Centers, Inc. permission to photograph, audio, or video tape my child during special activities or for news stories and advertising purposes. Consent(Required) I give permission for security monitoring.(Required)Consent(Required) I agree to and give permission for field trip and transportation policies.(Required)I give permission for my child to attend and be transported on field trips with Playmates. I have reviewed field trip rules (seat belts, staying seated, quiet voices, no open food/drinks, good manners) with my child.Consent(Required) I give permission for use of insect repellents(Required)In case of emergency when public health authorities recommend use of insect repellants due to high risk of insect borne disease, only repellents containing Deet will be used, and these are applied only on children older than two months. I give consent for staff to apply insect repellent once per day.Consent(Required) I give permission for use of sunscreen (SPF 15 or higher) anytime my child may be exposed for a long period in the sun.(Required)Consent(Required) Enrollment Agreement Consent(Required)I hereby enroll my child in Playmates Preschool and Child Development Centers, Inc. for the days and hours listed above. I have/will complete a site orientation and transition visit prior to my child’s first day. I agree to all center policies including behavior management and reporting of abuse and neglect and have been provided with a copy of those policies. Name(Required) Parent/Guardian’s Signature By typing your name above, you are electronically signing this form and affirming that the information provided is accurate and complete to the best of your knowledge.Date(Required) MM slash DD slash YYYY
