E.L.I.T.E Academics Summer Enrollment Child InformationFirst NameMiddle NameLast NameGenderMaleFemaleSchool NameGradeBirth DateAgeChild Home PhoneStreet AddressCityState/ProvinceZIP / Postal CodeChild Lives WithDoes child have disability?YesNoIf yes, explain disabilityParent/Guardian InformationFirst NameLast NameStreet AddressCity/TownState/ProvinceZIP / Postal CodeHome PhoneWork PhoneCell PhoneFaxEmail AddressOccupationEmployerEmergency ContactFirst NameLast NameEmergency Home PhoneEmergency Work PhoneEmergency Cell PhoneEmergency EmailMedical InformationInsurance Policy NumberHealth Insurance ProviderPrimary PhysicianPhysician AddressPhysician PhoneHospital PreferenceChild taking medication or treatment?YesNoIf yes, explainSpecial diet or food allergies?YesNoThe purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment .If yes, explainAgreementsParent/Guardian SignatureStart signing your signature hereYour browser does not support e-Signature field.Photo Release I hereby give permission for my child to be photographed during the E.L.I.T.E Academics Summer Camp . I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of E.L.I.T.E Academics and its affiliates.Parent/Guardian SignatureStart signing your signature hereYour browser does not support e-Signature field.I, the undersigned*, herby release discharge, indemnify, hold harmless and defend E.L.I.T.E Academics, its officers, employees and servants from any and all liability (claims, demands, losses, causes of action, suits, judgements) of any kind that I or my family may have against E.L.I.T.E Acadmeics due to death, personal injury or illness, loss or damage to property, or future causes that occur during the Summer Camp. In the event of any medical emergency, I authorize and consent for District to act on behalf for medical care deemed necessary for the participant.DatePrinted Name of Parent/GuardianSubmit
