Winter Camp Registration Form

Dec 20-22 & Dec 27-29

Camper’s Name:_________________________________ Age:__________

Parent 1 Name:__________________________________ Cell Ph:_________________________________
Parent 2 Name:__________________________________ Cell Ph:_________________________________
Home Address:__________________________________________________________________________
City:__________________________ Zip Code:_______________ Hm Ph:___________________________
Parent(s)Email Address:___________________________________________________________________

[Program Dates] My child will be attending the following days and weeks: Please circle:

Theme: Ice/Snow/Science Theme: Winter Olympics/Games

Wk 1 December 20 21 22 Wk 2 December 27 28 29
M T W M T W

[Program Hours, Tuition, + Billing Information]

Camp Fees: $40/day
5% discount for those that are attending all six days
5% Early bird discount if you sign up by Tuesday, Nov 30th.
Please make checks payable to “cash.” Checks can be mailed to GBCP, 3047-49 S. Robertson
Blvd, Los Angeles CA 90034

Registration Fee: $20.

Camp Hours: 9:00 a.m.-1:00 p.m.

Camper Ages: 2-6 yrs.

Registration fee and payment in full is required in order to reserve your camper’s space. Limited
enrollment.
(Tuition is non-refundable nor transferable. By enrolling in the program, I accept these registration, tuition and
refund terms).
For more info email us at info@greenbeginningpreschool.com or contact Green Beginning at (310) 841-6100.

No. of Weeks Attending ______ $ _____ + $20 Registration Fee = Total Amt Enclosed $_________
Pd by Ck# _____________

Parent Signature ___________________________________________ Date _________________________

[Camper Information] (Please disregard if child is already enrolled in GB)

Camper Name:________________________________ DOB:______________________________

Please Circle:
Tetanus shot current? Yes No Hearing Problems? Yes No
Asthma? Yes No Wear glasses or contacts? Yes No
Any relevant allergies Yes No If yes,
Explain________________________________________________________________________

List Medications and dosage:______________________________________________________

Any behavioral or medical problems:

Health Insurance: ____________________________ Policy No____________________________

Group No_____________________ Dr’s. Name_________________________________________
Dr’s Phone No._________________________
Name of the person you want us to contact in case of an emergency_________________________
Relationship_______________________ Ph No_________________________________________
Release: In case of emergency and I cannot be reached, I authorize Green Beginning Community
Preschool (GBCP) staff to obtain whatever medical treatment he/she deems necessary for the
welfare of my child. I hereby release, indemnify and hold harmless GBCP Directors and their staff
from any and all claims arising out of injury to my child. I also agree to accept full financial
responsibility for medical care provided to my child in case of an emergency.

Parent Signature___________________________________________ Date_________________

Authorized Pick Up: List the names, relationship, and phone numbers of the people authorized to
pick up your child from camp. All campers must be signed in and out daily with full signatures for
licensing and legal purposes.
__________________________________ __________________________________________

__________________________________ __________________________________________

__________________________________ __________________________________________