Camp 

10.0 ACADEMY Summer Camp & Swim Registration

181 Great Road, P.O. Box 454 Stow, MA 01775

Phone 978-897-8184 / Fax 978-897-8198

Family’s LAST NAME  :

HOME PHONE:

Parents Names

Mother

Father

Address

Town                        Zip

  Work Phone (       )              -                     ext. _____        Cell Phone (      )            -   

1st Child’s Name:

2nd Child’s Name:

3rd Child’s Name:

Date of Birth :                       M / F    age

Date of Birth :                       M / F   age

Date of Birth :                        M / F    age
Swim Lessons: Group /  Private Swim Lessons: Group /  Private Swim Lessons: Group /  Private
Session:      level       time: Session:      level       time: Session:      level       time:
Session:      level       time: Session:      level       time: Session:      level       time:
Session:      level       time: Session:      level       time: Session:      level       time:
Camp:  Full Day  or   Half Day Camp:  Full Day  or  Half Day Camp:  Full Day  or   Half Day
Weeks: Weeks: Weeks:

Extended Care per Week:

AM 8-9($25) _____ PM 3-5 ($50) _____

Extended Care per Week:

AM 8-9($25) _____ PM 3-5($50) _____  

Extended Care per Week:

AM 8-9($25) _____    PM 3-5 ($50) _____  

Camp Deposit:   $50/wk

Camp Deposit:  $50/wk

Camp Deposit:  $50/wk

Tuition due:

Tuition due:

Tuition due:

Please list any special needs, allergies, medications, learning disabilities or any other information we may need to make your child’s experience a positive one.

  

 

AUTHORIZATION OF PARTICIPATION: I give all members of my family permission to participate in any program (s), camps, swim, special events of  10.0 ACADEMY  I hereby certify that to the best of my knowledge my children/family are in sufficient physical condition to participate safely in all activities and I am willing to provide a Physician's certificate if so desired by the Director.  I understand that it is the expressed intent of 10.0 ACADEMY. to provide for the safety and protection of my children/family and in consideration for allowing my family to use these facilities,  I hereby forever release 10.0 ACADEMY Its officers, employees, teachers, and coaches from all liability for any and all damages and injuries suffered by my children/family while under  the instruction, supervision, or control of 10.0 ACADEMY.  I recognize that  participation in any sport, including gymnastics which involves height, motion and rotation, that injury can occur.  This includes severe injuries including permanent paralysis or even death.  I authorize 10.0 ACADEMY. to seek medical treatment at the nearest Medical Facility in case of emergency.

 

ENROLLMENT AGREEMENT AND REFUND POLICIES: This will secure a place for your child(ren) in a limited class/camp program.  Payments are accepted by Cash, Check, Master Card, Visa, or Discover.  No refunds or credits will be given to any students after the summer program has started or for missed classes, withdrawal, early dismissal or for illness. All summer programs are non- transferable to other persons or succeeding sessions.  A surcharge of $15 will be charged for any returned check.  10.0 ACADEMY reserves the right to cancel any classes due to weather or lack of enrollment. There are no Make ups permitted during the summer program (Swim Classes may be rescheduled or delayed due to severe weather).  This acknowledgment of risk and waiver of liability, having been read thoroughly and understood completely, is signed voluntarily as to its content and intent.  I hereby execute and deliver this waiver and release form, to permit my child's / children's participation in the program (s).  I have read and agree to the enrollment conditions as stated above.

Signature:_______________________________________________________ Date_________

Swim & Gymnastics Tuition: must be paid in full at time of registration, and are non refundable.  Discounts do not apply to Swim Programs. 

Camp deposits:  $50/week per child are due with application and are non refundable. Camp Discounts: 10% off your second child’s camp tuition or a second week. (Discounts apply to equal or lesser camp tuition). 

Camp balance: is due in full TWO weeks before camp start date, along with a Mass. State Health form or Standard Pediatrics Well-Child form.  No child can or will be admitted into camp without a current Health Form.  Camp size is limited and enrollments are taken on a first come - first serve basis.

Total Tuition Due: _______________ Enclosed payment _____________ Check #_____________

CCard# (mc/visa/discover)____________________________________________Ex Date ____/____   Zipcode______________

Signature:______________________________________________________________date_______________