Register for Summer Camps

Student Information

Student's Name

First Last

Entering Grade

School

Areas of Concern (Academically)

Parent & Emergency Contact Information

Mother's Name

First Last

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Work Phone

Father's Name

First Last

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Work Phone

Emergency Contacts

Name	Cell Phone	Work Phone	Relation to Student

Required Emergency Information

Allergies

Yes
No

TYPE & LEVEL of Severity

AUTHORIZATION OF CONSENT TO TREAT A MINOR*

I hereby authorize Benedictine Tutors to have my child transported to an area hospital in a medical emergency if parents and emergency contacts cannot be reached.

LIABILITY RELEASE*

Benedictine Tutors does not provide child care services. You are ultimately responsible for your child while he/she is at the Center. You agree to hold harmless, defend and indemnify Benedictine Tutors and its employees and owners. The employees of the Center are not liable for your child outside of the facility before the child enters or after the child leaves the facility.

I AGREE with the above statements and would like my child(ten) to participate in the Benedictine Summer Camps.

PHOTOGRAPHY & SOCIAL MEDIA RELEASE

At times, Benedictine Tutors may take photographs of your child for publishing in print or social media platforms. Please check below whether you provide, or not provide your consent and release for photographs to be taken.

I DO NOT want any photos taken of my child for publication in print or social media.
I DO grant permission for the staff of Benedictine Tutors to take photos of my child for publication in print or social media.

TERMS OF PAYMENT & SERVICE*

You agree to pay a one-time registration fee. You agree to prepay all summer camps registered for on a monthly basis. (June payments are due May 31st. July payments are due June 30th. August payments are due July 31st.) Camp fees are Non-Refundable and Non-Transferrable.

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