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Beverly Hills Sports Camp Registration Form

www.bhsportscamp.com
9663 Santa Monica Blvd. #736 Beverly Hills, Ca 90210 - Phone: (310) 273-5914

FAMILY INFORMATION

Mother's First Name Mother's Last Name Work Phone Cell
Father's First Name Father's Last Name Work Phone Cell
Mother's Occupation Father's Occupation Divorced Custody?
Home Address City State Zip
Home Phone Fax Email
Emergency Contact Relationship Phone

CAMPER INFORMATION

CAMPER 1



Name
Sex Grade in Sept. 2017
School
Camper's Birthdate (mm/dd/yyyy) Age
List friends your child would like to be grouped with:

Choose Program: Sports Camp or Girl's Club
(Select the appropriate days) M T W Tr F
Week 1 June 5 - June 9
Week 2 June 12 - June 16
Week 3 June 19 - June 23
Week 4 June 26 - June 30
Week 5 July 3 - July 7
Week 6 July 10 - July 14
Week 7 July 17 - July 21
Week 8 July 24 - July 28
Week 9 July 31 - August 4
Week 10 August 7 - August 10

EXTENDED CARE

($7.00 per hour/per child- PREPAY ONLY)
Early Care: (8:00am - 9:00am)
Late Care: (3:30pm - 4:30pm)

CAMPER 2



Name
Sex Grade in Sept. 2017
School
Camper's Birthdate (mm/dd/yyyy) Age
List friends your child would like to be grouped with:

Choose Program: Sports Camp or Girl's Club
(Select the appropriate days) M T W Tr F
Week 1 June 5 - June 9
Week 2 June 12 - June 16
Week 3 June 19 - June 23
Week 4 June 26 - June 30
Week 5 July 3 - July 7
Week 6 July 10 - July 14
Week 7 July 17 - July 21
Week 8 July 24 - July 28
Week 9 July 31 - August 4
Week 10 August 7 - August 10

TRANSPORTATION

(within our designated areas only)

YES - I would like BHSC to provide transportation for my child.
NO - I will provide my own transportation.

PICK-UP AUTHORIZATION:

Please list the names of anyone who is authorized to pick up your child(ren) from camp. All campers must be signed in and out daily by an authorized and responsible adult, unless our transportation service is being used.

Medical

Tetanus shot current? YES NO
Wearing glasses or contacts? YES NO
Athsma? YES NO
Hearing Problems? YES NO
Any relevant allergies:
Any medications:
Any behavioral or health problems:
In the event of a headache, please give my child:
Health Insurance Co.: Policy No.: Group No.: Phone No.:
In the event of an emergency I authorize the administering of medical care at the nearest facility for my child (name)

RELEASE:

Please Check and Sign
In case of emergency and I cannot be reached, I authorize BHSC Directors, to obtain whatever medical treatment he/she deems necessary for the welfare of my child. I hereby release, indemnify and hold harmles BHSC Directors and their staff from any and all claims arising out of injury to my child. I also agree to accept full responsibility, financial and otherwise, for the conduct of my child. I understand that there is no refund should my child be dismissed from camp for improper conduct.
Parent Signature:

Payment Information


AMOUNT: $

Payment by check: CHECK NUMBER Please send checks to address at top of page!
OR
VISA/MASTERCARD NUMBER: EXP. DATE NAME ON CARD: CVV:

I authorize Beverly Hills Sports Camp to charge my credit card number for the designated amount. SIGNATURE: