Summer Camp Registration Form

Use this form to send us your registration information. Please note, registrations are not complete until a deposit is received.
Please contact us if you have questions or would like more information.

Date of Application
Child's Name Nickname
Date of Birth Sex
Address

City Zip
Home Phone Email *

Parents/Guardians Father Place of Employment
Home Address (if different from above)

Email
Work Phone Cell Phone
Mother Place of Employment
Home Address (if different from above)

Email
Work Phone Cell Phone

Emergency Information Allergies to food or medication

Childs Doctor's Name

Emergency Contacts

Emergency Contact 1:
Name Address Phone
Emergency Contact 2:
Name Address Phone
Carpool List - Person(s) authorized to pick up child

Person NOT authorized to pick up child

Child's Age

Please enroll my child in the following camp sessions:

Check to enroll	Session Dates	Days /Times	Fee
	Drama Week July 5-8	Tuesday – Friday 9:30 am – 12:30 pm	$156
	Cooking Week July 11 – 15	Monday-Friday 9:30 – 12:30 pm	$225
	Music Week July 25-29	Monday-Friday 9:30 – 12:30 pm	$195
	Art Week August 1-5	Monday – Friday 9:30 am – 12:30 pm	$200
	Tae Kwon Do Week August 8-12	Monday – Friday 9:30 am – 12:30 pm	$195

Payment Notes:

A non–refundable registration fee of $25.00 confirms a place in our program.
Full payment is due by June 1, 2011
Please make your check payable to KESHET CHILD DEVELOPMENT CENTER.

Camp Details:

Each day’s schedule will include free play in our toy filled classrooms, 45 minute -1 hour specialty class, snack, playground, lunch, stories and additional theme related activities.
We will go to the playground daily (weather permitting). Campers should wear cool comfortable clothing and closed shoes or sneakers each day. No sandals, crocs or flip flops please.
Apply sunscreen to your child before coming to Camp. Teachers cannot apply sunscreen.
Keshet will provide a healthy snack each day. Campers should bring a Dairy or Vegetarian lunch each day including a drink. No meat is allowed in the school. Lunches are not refrigerated, so please use an insulated bag or ice pack.
Proof of the child’s identity (birth certificate or passport) and a health form signed by a doctor must be submitted before a child can attend camp.
Camp Activities start promptly at 9:30 am. Please be on time!

Agreements:

Keshet agrees to notify the parents/guardians whenever the child becomes ill and the parent /guardian will arrange to have the child picked up as soon as possible if so requested by the camp.
The parent/guardian authorizes Keshet Child Development Center to obtain immediate medical care if any emergency occurs when the parent /guardian cannot be located immediately.
The parent/guardian agrees to inform Keshet within 23 hours or the next business day after the child or any member of the immediate household has developed a reportable communicable disease as defined by the State Board of Health, except for life threatening diseases, which must be reported immediately.

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Contact

Keshet Child Development Center
758 23rd Street South
Arlington, VA 22202-2420
(703) 535-5525
preschool@keshetcdc.com

Keshet Child Development Center
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