Summer registration form

The Clubhouse - School-Age Care
Summer Day Camp
School District of Amery • 715-268-9771 x220 • 555 Minneapolis Ave, Amery, WI 54001 • www.amerysd.k12.wi.us
New Clubhouse Family Returning Clubhouse Family Parent/Guardian 1
• 469 Minneapolis Ave • Amery, WI 54001
Parent/Guardian 2

Relationship to child(ren)
E-mail
ion fee to A Children (enroll all children in the family entering grades K-6 who may use the Clubhouse Day Camp this summer)
If you receive county assistance, please provide Caseworker name: Note: You are responsible for any costs not paid by the county. Written authorization from county agency must be on file
before a child begins this program.
I agree to make tuition payments and to read and follow program policies as stated in the Family Handbook. I under-
stand that care cannot be given until registration is signed and registration fee is paid. I understand that enrollment in
The Clubhouse can be terminated if terms outlined in the Family Handbook are not met.
Parent/Guardian
The Clubhouse Child Emergency/Permission Form Date ___________
The data supplied on this form will be used in the event of an illness or emergency of
your child. This data will constitute a private record and will not be released to other
parties.

Child’s Name: Last
Birthdate month
Current Grade
Current homeroom teacher
Child’s Doctor/Clinic
Doctor/Clinic Phone #
Special health-related conditions (diet, physical restrictions, medications, allergies, existing long-
term or continuous illnesses, etc.)
If a child requires medication of any type (including bee sting kits or asthma inhalers), please bring the
medication to the Site Leader. Any medications, including Benadryl, Tylenol, etc., need to be provided
by the parents; please plan to have medications available upon admission to the Clubhouse. Parent
permission forms are to be signed for all medications given. A doctor’s form must be completed for
medications given longer than 10 days. Medication must be in the original container with specific in-
struction as to dosage, etc. At no time are students allowed to keep medication of any sort.

Prior hospitalization or injuries

Parent/Guardian 1
Parent/Guardian 2
Persons from different residences who are AUTHORIZED to take your child from the program
and assume emergency responsibility if a parent/guardian cannot be reached. (List at least 2
and please make these people aware that you have listed them): Do not list parent/guardians

1) Name

List any specific persons who are NOT AUTHORIZED to take your child by court order. You
must provide staff with a copy of the court order.
1) Name

Other siblings who attend The Clubhouse

Publicity Release
I, the undersigned parent/guardian, grant The Clubhouse my permission to use photographs/video of
the aforementioned child for public relations and/or informational publications for the School District of
Amery ONLY. This may include, but is not limited to, submissions to the School District of Amery
newsletter and website, The Clubhouse publications, and the Amery Free Press.
If you DO NOT give permission, please check box
In the event of a non-emergency situation, such as sickness, minor injuries, or behavioral issues, I re-
quest that Clubhouse staff contact me and I will make arrangements to transport my child from the
school or field trip site within one hour.
In the event of a serious accident, illness, or if unable to contact me, I hereby authorize Clubhouse staff
to make whatever arrangements they deem necessary.
I have read the above statements and I agree to supply the data on this form with full knowledge of the
information in these statements.
Parent/Guardian
Signature
If any information provided on this form changes during the school year, please contact the Site Leader to update necessary information—Thank You School District of Amery—The Clubhouse Date ____________
Getting To Know You
The data supplied on this form will be used to help Clubhouse staff effectively work with your child. This data will constitute a private record and will not be released to other parties. Child’s Full Name Please list the people who live within your household and what their relationship is to your child. Name If your child has any Learning, Social, or Developmental conditions, please describe them: If your child has any activity restrictions, please describe them: Please list your child’s hobbies, talents, and athletic interests: Is there any other information you would like to share about your child? Thank You!!

Source: http://www.amerysd.k12.wi.us/community/Clubhouse/Summer%20Registration%20Form.pdf