Indulgence Summer Camp Registration 2019

Camper Information

Camper’s Full Name:

Address:

Camper’s Mobile Number: _ Sex: ▢ M ▢F Date of Birth: Age: Grade Entering:

Names of Siblings attending camp:

Please Note: Registration fee must be paid in advance to reserve your Campers Spot
There is an additional Fee for Extended Care.

Mother or Guardian ~ Legal Custody of Child: ▢Both Parents ▢Mother ▢Father Father or Guardian ~ Legal Custody of Child: ▢Both Parents ▢Mother ▢Father

City, State, and Zip Code: City, State, and Zip Code:

Home Phone: Home Phone:

Work Phone: Work Phone:

Mobile Phone: Mobile Phone:

Email address: Email address:

▢ No additional person may pick up my child

▢The following additional persons are authorized to pick up my child from iCamp

Name Relationship Home Phone # Work Phone # Cell Phone #

1.

2.

3.

Indulgence Summer Camp, 3903 Main Street, Suite 7, Jacksonville, Florida 32206 (904)694-055
Camp Fees:
➢ Required Fees: ➢ Optional Fees
►$25.00 ~ Non-Refundable Registration Fee ►$200.00 ~ Field trips
►$40.00 ~ Per Camper, Per Week ►Before care 6am-8am: $5.00 Per Camper\Week
►$14.00 ~ Camp T-shirts ►Aftercare 5pm-6pm: $5.00 Per Camper\Week
►Extended Care AM/PM: $10.00 Per Camper\Week

Please list your child’s start date and end date for our Summer Camp program below. Also, for each
Summer Camp week posted below, please mark which weeks child will be attending. As a reminder, if your
child is absent for an entire week, you must provide two weeks' notice in writing.
• Summer Camp starts: Monday, June 3rd and ends Friday, August 9th
• Drop-off: by 9:00 am
Summer Camp start date: Summer Camp end date:

Summer Camp weeks (mark the weeks attending for each week listed below):

 June 3rd-June 7th

 June 10th- June 14th
 June 17th- June 21st
 June 24th- June 28th
 July 1st-July 3rd (Closed for July 4th and July 5th)
 July 8th-July 12th
 July 15th- July 19th
 July 22nd- July 26th
 July 29th-August 2nd
 August 5th- August 9th (No afternoon extended care August 9th)

Signature: Date:

Indulgence Summer Camp, 3903 Main Street, Suite 7, Jacksonville, Florida 32206 (904)694-055
 RELEASE AND INDEMNIFICATION AGREEMENT (Mandatory)

The parties to this Agreement are ____________________________________________of

(Parent Name[s])
_______________________________________________________, who is either the parent
(Full Address)
or guardian (referred to herein as “Parent”) of __________________________________ (hereinafter
(Camper Full Name)

“the Child”), and the Indulgence Company Inc (Indulgence Summer Camp), entering into this Agreement on
behalf of the Child with the Camp and, as such, acknowledges and agrees that the Child shall be subject to all
the rules and regulations of the Camp, as such are promulgated from time to time, whether upon the Camp
premises or off the Camp premises on field trips, excursions and outings.

The parties agree that the Camp shall supervise and manage the Child (including during field trips,
excursions, and outings), and that the Camp shall utilize ordinary care regarding the same. In return, Parent
agrees that he/she shall not institute a suit in equity or in law, or both, resulting from or related to any loss,
damage, injury or the like arising from circumstances which are not within the reasonable control of the Camp
or resulting from the Child’s failure to abide by the Camp’s rules and regulations, particularly as same apply to
violations of the Camp Code of Conduct by the Child.

Parent further agrees that he/she shall indemnify and hold harmless the Camp, its parent company,
personal representatives, successors, assigns, officers, agents, volunteers, and employees, from any claim
for any loss, damage or injury incurred as the result of the Child’s failure to abide by the Camp’s rules and
regulations, particularly as same apply to violations of the Camp Code of Conduct by the Child.

Parent agrees that this Agreement shall inure to the benefit of the Camp, its parent company, agents,
servants, volunteers, employees, and independent contractors and shall bind Parent, and Parent Spouse, heirs
and legal representatives, if any.

______________________________________ ________________________
Parent Date

______________________________________ ________________________
Witness Date

Indulgence Summer Camp, 3903 Main Street, Suite 7, Jacksonville, Florida 32206 (904)694-055
 MEDICAL TREATMENT AUTHORIZATION (Mandatory)
PARENT’S NAME______________________________________________________________

HOME PHONE________________________WORK_______________CELL_______________

CHILD’S NAME______________________________GRADE______ DATE OF BIRTH__________

EMERGENCY PH #_________________NAME AND RELATIONSHIP: ______________________________________________

EMERGENCY PH #_________________NAME AND RELATIONSHIP: ______________________________________________

EMERGENCY PH #_________________NAME AND RELATIONSHIP: ______________________________________________

MEDICAL HISTORY:
Family Doctor:______________________________________________ Phone:_____________________________________

Insurance Company: _________________________________Policy/ID#: ____________________

Does this child have any allergies, diseases, disabilities, or medical history the camp should be aware of in case of
emergency? Yes_____________ No____________

If YES, please explain: ___________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Is the child on any medications? Yes_________ No__________ If YES, please explain:

________________________________________________________________________________________

________________________________________________________________________________________

This notice gives the Indulgence Summer Camp my permission to authorize treatment for my child,
__________________________, in case of any emergency, illness or injury until I can be
(Camper Full Name)

contacted. This notice is effective from the enrollment date until the child’s withdrawal date.
I, _______________________, allow/do not allow (circle one) the student indicated above to take
(Parent Full Name)

Tylenol or its generic equal as s/he requests for headache or other pain. Please state any limitations to the previous

statement in the space below: _______________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Parent’s Signature: ____________________________________________________ Date: ______________________

Indulgence Summer Camp, 3903 Main Street, Suite 7, Jacksonville, Florida 32206 (904)694-055
 CAMPER CODE OF CONDUCT

In order to maintain a safe and peaceful camp environment we require parents and campers to read and comprehend
the importance of abiding by the following code of conduct:

I will follow the camp schedule. I will bring only listed and approved items to camp. I understand weapons of any kind,
electronics, non-prescription drugs, and other items which can violate a safe, peaceful camp environment are not allowed.
I will respect counselors, directors, and other campers by not using foul language, name calling, or fighting. I will follow
all safety rules set forth by the camp staff.

Camper Name: _________________________ Date: ___________________________

I agree to help my child abide by this code of conduct.

Parent Signature: ___________________________ Date: ___________________________

Indulgence Summer Camp, 3903 Main Street, Suite 7, Jacksonville, Florida 32206 (904)694-055
 AUTHORIZATIONS & POLICIES

________ PARENTAL PERMISSION FOR PHOTOGRAPHY AND VIDEO USE I grant Indulgence Summer Camp
permission to use my son/daughter’s picture for promotion of the camp, whether in newspapers, newsletters, camp
promotions or for teaching purposes.

_______ PARENTAL CONSENT AND PERMISSION TO LEAVE PROPERTY FOR FIELD TRIPS (ALL
AGES) I grant my child permission to leave the Indulgence Summer Camp property for field trips which correlate to the
camp lessons. I understand my child will be under supervision by camp staff and is expected to comply with all rules of
the camp and any destination. My child has permission to be transported to and from camp field trips by the camp
providers.

_______ EARLY ARRIVAL/LATE PICK UP FEES I have been informed of Indulgence Summer Camp schedules. I
understand that Indulgence Summer Camp fees do not include any before or after care and if I have not enrolled my
camper in extended care and they arrive early (before 8 am) or are picked up late (after 5:00pm) I will be assessed and
agree to pay any fees applicable to providing extended care

_______ PERMISSION TO RIDE: I (We) hereby grant permission for said child to ride in our vans or paid bus to any
field trips or off-site outing.

MEDICAL TREATMENT: I authorize school representatives to obtain medical treatment for my child in case
of serious illness or injury and agree to pay for such treatment. I have noted any and all special health-related conditions,
diagnoses, and/or allergies regarding my child.

PARENTS AGREEMENT TO PAY: I am responsible for making weekly tuition payments as set forth by
Indulgence Summer Camp. Payments are due on Monday of each week and become delinquent Monday close of
business. A $10.00 late fee will be assessed each day of the week Until fee is paid. If fee is not paid by the Friday of the
same week, camper will not be allowed to attend camp. Payments are accepted in the form of cash, check, Debit, VISA or
MasterCard only.

HOLIDAYS: Our center will be closed July 4th and July 5th. We will not be having extended care on the last day
of camp August 9th

PHOTOGRAPH RELEASE FORM: the parent/ guardian listed below, authorize Indulgence Summer Camp to
photograph and video my child named below. I understand that these photographs may be used for public/iCamp Website
display and/or advertising purposes. I give consent to have my child's photograph taken.

WITHDRAWAL: A two-week notice is required when withdrawing from our summer camp or to make changes
to summer camp weeks selected to attend.

_______ I am aware and agree to the following GENERAL POLICIES: *Tuition and Pick-up Policy, Absences and
Payment Policy, Behavior

Parent/Guardian Signature: _________________________________________________________ Date: ________

Indulgence Summer Camp, 3903 Main Street, Suite 7, Jacksonville, Florida 32206 (904)694-055
 CAMP ENROLLMENT CONTRACT (Signature Mandatory)
Both parents, guardians, or other persons responsible for payments should read all the provisions of this
Contract, complete the required information, sign and return the Contract to the camp office accompanied by a non-
refundable registration fee of $25. A student is accepted for enrollment when the Contract has been delivered to
Indulgence Summer Camp. No amendment to this Contract and no alteration or addition to the printed terms hereof
will be effective without the express prior written approval of the Camp Administrator.
In consideration of the acceptance of this Contract by Indulgence Summer Camp, the undersigned agrees to
pay the required TOTAL CAMP COST AND FEES and agrees to be bound by the provisions of this Contract. So
long as cost and fee payments are not delinquent, camp payments are due no later than the first day of camp.
Enrollment in camp is conditioned upon the following terms:

1. A non-refundable registration fee of $25

2. Students not enrolled in extended care must be dropped off no earlier than 8am and picked up no later than
5:00pm or additional fees for extended care will be assessed.

3. Campers that will not be attending for a week or weeks must submit a 2-week notice advising

4. Half of field trip fees must be paid the first day of summer camp on top of weekly tuition ($100)

5. By my signature below I am agreeing to the provisions required for my child to enroll.

Person Responsible for Payment Date

Indulgence Summer Camp, 3903 Main Street, Suite 7, Jacksonville, Florida 32206 (904)694-055