LE LYCÉE FRANÇAIS DE LOS ANGELES
LE LYCÉE’S SUMMER CAMP
3261 Overland Ave, Los Angeles, CA 90034-3589
Attention: Summer Camp Registration
5 WEEK S : JUNE 26 - JULY 28, 2017
Register with cash, credit card, or check.
All program fees & payments are non-refundable.
Call or email: [email protected]
Tel: 310-836-3464 #310 Fax: 310-558-8069
R E G I ST R AT I O N F OR M
One (1) form for each child
No Registration Fee!
Full Day (8:30 a.m. – 4:00 p.m.)
FREE Extended Care (4:00 p.m. – 4:45 p.m.) Snacks and games included!
Qualified students from other schools are welcome. Include your child’s latest
report card and a good disciplinary report with this Registration Form.
u Use a new form to register any additional campers. Download additional
forms at LyceeLA.org.
u
u
u
u
Student’s Name Last: ____________________ First: ___________________
Date of Birth: _______________ Grade completed in 2016-17: ___________
Name of school attended in 2016-17: ________________________________
Please indicate R which week(s) your camper will attend:
Week(s):
p 1 ($400)
p 4 ($400)
p 2 ($350)
p 5 ($400)
p 3 ($400)
p ALL ($1,950)
If by June 2017, your child completed K1, K2, or 1st grade; he/she will be a Chipmunk.
If by June 2017, your child completed 2nd - 9th grade; he/she will be a Barracuda.
Please register my child for the following:
*
The Chipmunks
Week Numbers: __________
Total Due: $_____________
*
The Barracudas
Week Numbers: __________
Total Due: $_____________
PRINT Name of Parent/Guardian:
Home Address:
Home Phone:
Mobile Phone:
Email Address:
Signature of Parent/Guardian:
HEALTH INFORMATION
PLEASE PRINT CLEARLY. To enable proper care of your child, please fill in the
following completely and accurately:
Allergies (Food or Animal or Medicinal):
Heart Trouble:
Asthma:
Diabetes:
Epilepsy/Convulsions:
Plant Allergies or previous Plant Poisonings:
Severe reactions to Insect Stings:
Recent Operations or Serious Injuries:
Other:
PARENTS’ CONSENT FOR EMERGENCY MEDICAL TREATMENT
We, the undersigned parents/guardians of __________________________, do
hereby authorize the adult leaders or agents of Le Lycée Français de Los Angeles to
act as agents for the undersigned to consent to any medical or surgical diagnosis or
treatment or hospital care deemed advisable or administered by a duly licensed
physician, in the event such help of an emergency nature becomes necessary. This
authorization is given pursuant to the provision of Sec. 25.8 of the Civil Code of
California and in no event will Le Lycée Français de Los Angeles, its officers, leaders,
or agents be held liable for any first aid or surgical treatment or procedures performed pursuant to this consent.
SIGNATURES OF PARENT(S) OR LEGAL GUARDIAN(S):
1.
Work Phone:
Date:
Print Name of Signing Parent/Guardian
Date:
2.
Print Name of Signing Parent/Guardian
Date: