SA Summer Camp Registration - Salisbury Academy

1. Camper First Name *

2. Nickname/Preferred Name *

3. Last Name *

4. Date of Birth (mm/dd/yyyy) *

5. Gender * (1 required)

Male Female

6. Grade in Fall 2021 * (1 required)

K 1 2 3 4 5

7. Camper's Contact Address *

8. Camper's Primary Telephone Number *

9. Guardian Information (description optional)

10. Father/Guardian

11. Father/Guardian Cell Number

12. Mother/Guardian

13. Mother/Guardian Cell Number

14. Preferred Email for Contact Regarding Camp *

Select Your Camp Weeks: $175 per week for full-day camp (Monday-Friday, 8 a.m.- 5:30 p.m., includes Muddy Sneakers/SA Outing Wednesday and Big Splash Friday). $100 per week for half-day camp (Monday-Friday, 8 a.m.-noon).

15. * (1 required)

July 5 Full-day Camp July 5 Half-day Camp July 12 Full-day Camp July 12 Half-day Camp July 19 Full-day Camp July 19 Half-day Camp July 26 Full-day Camp July 26 Half-day Camp

16. Insurance and Medical Information (description optional)

17. Insurance Information (Name of company, policy holder, and any relevant policy or group numbers) *

18. Family Doctor (name and contact info of physician) *

19. Does your camper have any allergies? *

20. Please add any information that will assist us in providing excellent care for your child.

21. Emergency Contact (description optional)

22. In Case of Emergency, Please Contact (name, relationship, phone) *

23. Please list up to 3 additional people allowed to pick your child up from camp.

Completing Your Registration

Payment:
A minimum deposit of $20 per camper per week of camp is required as a non-refundable processing fee and will secure your child's place in your desired week(s).

Electronic payment for the deposit or full cost of camp can be made using the link found on next page after you submit this registration form. Checks should be made payable to Salisbury Academy. Please note "Summer Camp" in the memo portion of the check. Or,

Mailing Address:
2210 Jake Alexander Blvd, N.
Salisbury, NC 28147

You will receive an email from Camp Director Penny Moss confirming your registration and another email when your deposits have been received.

Final payments are due at drop-off on the Monday of each week of camp.

Thank you for your interest in Salisbury Academy Summer Camp. We look forward to seeing you!

Note

Registration is subject to camp availability. All sessions are subject to minimum and maximum enrollment.

Release of Liability

While my child is attending Salisbury Academy, I will provide health insurance for myself/my child and assume responsibility for any and all costs of medical care. I warrant that the participant – either my child or me – is in good health, and that I know of no reason that he/she should not participate in strenuous activity.

In consideration for furnishing transportation and other services to enable me/my child to participate in activities, I hereby voluntarily release and discharge the Salisbury Academy staff, Salisbury Academy Board members, agents, employees, or parent volunteers from any and all liability or claims for any injury, illness, death, damage to myself or my child or my property arising from, or in any way connected with my participation in field trips or activities to the extent I maintain health insurance for my child as stated above for such damages or claims.

This release and discharge is specifically limited to accidents for which Salisbury Academy, its employees or agents, have not been found to be negligent, whether third party insurance is present or otherwise.

I have carefully read this release of liability and fully understand its contents. I sign this agreement of my own free will.

24. Release of Liability as stated above * (1 required)

I agree