Summer Camp Registration Form

Child's* Last Name______________________ First Name_______________________ Middle Initial___

Mother's*Last Name_____________________ First Name_______________________ Middle Initial___
Father's*LastName______________________ First Name_______________________ Middle Initial___
Does child live with a legal guardian other than mother or father? Yes No
If yes, Guardian's Last Name____________________, First Name________________, Middle Initial___
Street Address*_________________________________ City* _____________ ZIP Code* ________

Parent/Guardian Primary Phone* Email*____________________

(You may be contacted by The Childrens Trust for quality improvement purposes)

Child's Gender* Male Female Child's Date of Birth (mo/day/yr)*

Child's Race*: American Indian or Alaskan Asian Black or African American
Pacific Islander White Other, please specify_______________
Child's Ethnicity*: Hispanic Haitian Other, please specify_______________
Is Child Proficient in English?* Yes No Childs Country of Origin ____________________
Other Language(s) Spoken in the Home* Spanish Haitian-Creole Other___________ None

Miami-Dade County Public School ID#* No MDCPS ID Prefer not to give

Last 4 Digits ONLY of Child's Social Security#* No SSN Prefer not to give
Childs Current Grade*__________ Child's Current School* ________________________________
Does Child Have Health Insurance (ex., private insurance, KidCare, Medicaid)?* Yes No
(If not, we may be able to help you find affordable coverage-call 211 or visit www.thechildrenstrust.org)
Does Child Have a Documented Disability?* Yes No
If yes, do you have (check all that apply)*
an Individualized Family Service Plan (IFSP; if under 3) a diagnosis by a state certified/licensed professional
an Individualized Education Plan (IEP) at school system (ex., psychologist)
a Section 504 Plan disclosure by the parent or guardian describing the
childs specific condition and/or need for
a medical diagnosis from a doctor
accommodations
If yes, how would you best classify the disability type(s)? (check all that apply)*
Autism Spectrum Disorders Hearing Impairment (or deaf) Speech/Language Impairment
Chronic Medical Condition Intellectual Disability (or MR) Visual Impairment (or blind)
Developmental Delay (if under 5) Learning Disability Other Disability______________
Emotional/Behavioral Disorder Physical Disability
If you are interested in other services funded by The Childrens Trust,
please call 211 or visit www.thechildrenstrust.org

I give my permission for this information to be submitted to The Children's Trust for program
monitoring and evaluation purposes. The Childrens Trust provides funding for the program.

PARENT/GUARDIAN SIGNATURE* __________________________________ DATE*______________

_
For Staff Use Only (MUST BE COMPLETED)

ORGANIZATION* ArtSouth_SITE LOCATION* Miami Dade College Homestead Campus @500 College Terrace, Homestead, FL 33030
*Required fields Revised 03/24/16
1. My child has permission to take field trips planned with the classes.
2. I understand that ArtSouth is not responsible for any personal items (i.e. clothing, games, ipods, cell
phones or money) my child brings to camp.
3. I give permission to ArtSouth, Miami Dade College and all persons acting with its permission, the right
and permission to obtain, use copyright, and/or publish photographic or video images of the above named
registrant, in which the registrant is in whole or in part. It is my understanding that such pictures are
for the purpose of art, advertising, trade, and any other lawful purpose whatsoever. I understand that I
will not have any opportunity to approve nor review the finished product that may be used in connection
therein or the use to which it may be applied.
4. Authorization for Emergency Medical-Surgical TreatmentI understand that in the event I
cannot be reached, I hereby grant permission to the physician or hospital selected by the camp
administration to secure proper treatment for, order injection, anesthetic, or perform surgery on my
child. I hereby give permission or arrange necessary transportation to a hospital. I understand that
ARTSOUTH will not be held liable for injury or damage to my child(ren) while on campus or field trips.

________________________________________ _________________________________
Parent/Guardian Signature Date

ArtSouth
5825 SW 68th ST.
Suite 2-202
South Miami, Fl. 33143
Phone (305) 662-1423 FAX: (305) 662-1451
www.artsouthhomestead.org
info@artsouthmiami.org

Early Bird Registration Fee $25_____Cash______Check#________

Tuition Fee $150 per 2-week session ($75 per week)

Registration Fee $25 _____ Cash _____Check#________ Tuition

$170 per 2-week session ( $85 per week)

Session 1: June 20- July 1 ________Session 2: July 5-July 15________ Session 3: July 18-29________ Session 4: Aug. 1-5________

After Camp Care is available for all campers from 4 p.m. until 6 p.m., Monday through Friday for
an additional cost of $20 per week (cash only, due at the beginning of the week).

_____ Yes, I need After Camp Care for my child.

PAID AMOUNT: __________ RECEIPT #: ______________

*Required fields Revised 03/24/16

 Camp Staff Member
Print Name: ________________________

Emergency Contact and Pick-up Authorization

Camper's Last Name: ___________________________ First Name__________________________

Date of Birth: _______________ Sex: F M

Name of Parent(s) / Guardian(s):

1) ______________________________________ Phone # _________________ Additional # _________________

2) ______________________________________ Phone # _________________ Additional # _________________

Name of individual(s) allowed to pick-up the student in addition to the names listed
above. (Persons not on this form WILL NOT be allowed to pick up any student. Photo ID will be required)
1) __________________________________________________ Relationship ___________________________
2) __________________________________________________ Relationship ___________________________
3) __________________________________________________ Relationship ___________________________
4) __________________________________________________ Relationship ___________________________

My son/daughter has the following allergies:

__________________________________________________________________________________________________
__________________________________________________________________________________________________

He/she takes the following medications (staff will not administer any medication):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Any other special concerns we should be aware of (medical, emotional, dietary):
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Primary physicians name:

_______________________________________ Phone # ___________________________

Parent/Guardian Print Name

Parent/Guardian Signature Date

Student Code of Conduct and Responsibilities
The Miami Dade College mission is to provide opportunities for learning and serving the community. To accomplish this,

and responsibilities that each camper must adhere to during Kids/Teen College-related activities:

Be ready to learn and have fun.

Refrain from using inappropriate language, threats or inflammatory statements.

Follow teachers directions in the classroom and during any related activities.

Do not engage in any hostile, intimidating, domineering, or threatening behavior with the aim or purpose of physically affecting
another individual.

Use and access the Colleges technological resources such as computers, printers, Internet and software appropriately.
The College expects you to utilize these services in an ethical and legal manner consistent with Federal and State law as
well as Miami Dade College policy and procedures.

Do not bring weapons of any kind to Kids/Teen College.

Respect Miami Dade Colleges drug-free environment. Possession of any illegal or controlled substance is prohibited.

Inform MDC summer camp staff if a student requires a prescribed medication.

Violation of any of the guidelines set forth in the Student Code of Conduct and Responsibilities may result in the fol-
lowing disciplinary measures:

Age/developmentally appropriate removal from activities for a determined period of time.

Parent/guardian contact via telephone or in writing.

Removal from the program.

Student illnesses and preventive measures

Students who are ill upon arriving at camp, or become ill during the day, including having cold-like symptoms (fever/
nasal congestion, sore throat or cough) will be excluded from daily activities. Parents/guardians will

mouth with a tissue when coughing or sneezing, or coughing or sneezing into their sleeve if a tissue is not available.
They should frequently wash their hands with soap and water, or use hand sanitizer if soap and water are not available.

I have read and understood the Miami Dade College Summer Camp Code of Conduct and Responsibilities and I
promise to abide by all of the above stated guidelines.

Parents signature: ______________________________________ Date: ___________________

Childs signature: _______________________________________ Date: ___________________