www.beyondthebelldaycamp.com
PLEASE FILL OUT THIS FORM ONLY IF YOUR CHILD IS ATTENDING THE BEYOND THE BELL SUMMER PROGRAM
STUDENT ENROLLMENT FORM ~
Enrollment Date: _______________________
Child’s Name:______________________________ Date of Birth: _________Age:_____
Days of the week child will be Attending Beyond the Bell: ___________________________________________
Grade and Teacher:_______________________________________________________________________
Child’s Home Address: _____________________________________________________________________
Parent’s Address if different than child: _______________________________________________________
Child’s Home Phone: ___________________ Parents home phone if different than child: __________________
Email _________________________________________
Mother’s Name:________________________
Father’s Name:______________________
Work. No.:
________________________
Work No.:
_____________________
Cell No.:
________________________
Cell No.:
______________________
Place of employment ____________________
Place of employment __________________
Work Address: _________________________
Work Address: __________________________________
IF neither parent of guardian can be reached, in case of emergency, call: List name, Phone numbers and address:
______________________________________________________________________________________
Persons authorized to pick-up your child include phone numbers: ______________________________________
______________________________________________________________________________________
Persons who are NOT legally permitted to pick-up your child: ________________________________________
Child’s Doctor include Number and address: _____________________________________________________
Dentist include Number and address: __________________________________________________________
Allergies and/or health concerns: ___________________________________________________________________________
**Please attach a copy of current immunization records**
**Por favor agregue una copia de las vacunas mas recientes del niño/a**
Authorization for child to view “G” and “PG” rated videotapes
I give my permission for my child to view “G” and “PG” rated videotapes at Beyond the Bell.
Dated:_____________________
By:_____________________________
Signature of Parent or Guardian firma del Padre o Guardián
Authorization for Child to Sign Himself/Herself in: I give permission for my child to sign him/herself in to the program. Beyond the Bell accepts no
responsibility for ensuring the attendance and arrival of the child. As a courtesy, we attempt to contact parents by phone if their child does not sign-in to the
program. It is the parent’s responsibility to ensure the classroom teacher, the child and Beyond the Bell know the days of attendance and that updated phone
numbers are on file with the school and Beyond the Bell.
*Additional form MUST be signed if your child will be signing themselves out at the end of the day.
Field Trip/Activity Authorization: I give my permission to Beyond the Bell and/or its employees to take my child on walking field trips, use of public
transportation and school buses and for my child to participate in any of the activities associated with the program. I understand that my child’s participation in this
program, in general, could involve various risks, hazards and dangers which may include risks of physical harm and injury due to participating in the activities or
traveling to and from locations outside of the school facility. I understand that Beyond the Bell undertakes every reasonable effort to make the activities safe, but I
also recognize that it is impossible to guarantee the safety of each individual involved in such activity or to guarantee that the activity will proceed exactly as
planned. I hereby assume all risks that could be posed to my child and indemnify and hold harmless Beyond the Bell, its staff, agents and employees from any liability,
claim, cause of action or demand arising from my child’s participation in this program.
Dated:___________________
By:___________________________
Signature of Parent or Guardian
Medical Authorization: In case of serious illness or injury when neither parent can be reached, will you allow your child to be transported to the doctor or
hospital by an employee of Beyond the Bell? ___YES ___ NO
I hereby give permission to Beyond the Bell to secure emergency medical and/or surgical treatment for the above named minor child while in the care of the above
named school. All expenses of such care will be accepted by the parents. . I will hold the Beyond the Bell staff, agents and employees harmless and indemnify them
from any claim, cause of action or demand arising out of any form of (or lack of) medical or emergency treatment rendered to the student.
Dated: _____________
By:________________________________
Signature of Parent or Guardian
Acknowledgement of Policies and Procedures: I have read and understood the policies and procedures of Beyond the Bell:
Dated: _____________
By:________________________________
Signature of Parent or Guardian
Please enclose $25 annual family registration fee. Make checks payable to Beyond the Bell.
beyondthebelldaycamp.com [email protected] 707-631-3993
www.beyondthebelldaycamp.com
Beyond the Bell~ Summer Liability Waiver Form
Dear Parents: The following is a list of all field trips and/or special programs that are possibilities for the summer.
Please initial in the space provided for those activities you will allow your child to participate in. A weekly calendar will
be provided with activity information. Please review these calendars as they will serve as reminders and help you to
prepare for each week of Beyond the Bell. Beyond the Bell Staff will supervise all events.
_______ Swimming (Public swimming pools with lifeguards)
_______ GWS Center for Arts
_______ Adventure Park Rides
_______ Bowling
_______ Magic Show
_______ Mini-Golf
_______ Nature walks
_______ Biking – MUST wear a helmet
_______ Hiking
_______ Caving
_______ Fishing
_______ Challenge Course Activities/Zip Line
_______ Bananas
_______ Horse Back Riding
_______ Karate
_______ Cross fit
_______ Dance
_______ Sports
_______ Pottery
_______ Cheerleading
_______ Yoga
_______ Drama
_______ 3-D Art
_______ Run Club
_______ Gymnastics
_______ Jewelry
_______ Cooking
_______ Nature Museum
_______ Zip Line
_______ Rafting
_______ Animal Shelters
_______ Frisbee Golf
_______ Library
_______ PG movies – previously screened by the Beyond the Bell Director
_______ Arts and Crafts
_______ Media Release –Permission to take photos of your child for media and promotion
_______ Transportation by school bus or public transportation or Beyond The Bell 15 passenger Van
_______ Walking field trips within the community
*If any trips other than the ones listed above are planned, additional permission forms may need to
be signed*
Most trips away from the site will be walking field trips. In addition Beyond the Bell may utilize the city public bus system to get
to and from locations. Please be advised that at this time the buses are not equipped with seat belts. All applicable safety rules
are given to the children every time they board the bus or begin a walk.
Please sign the permission/waiver form below to indicate approval for the trips you have initialed and approval for mode of
transportation provided.
I give my permission for______________________________________ to attend the above checked activities with the
Beyond the Bell~ Summer program. I acknowledge that my child’s participation in this activity involves an inherent risk of
physical injury to any individual undertaking such activity or damage to the property of such individual. The undersigned
expressly assumes such risk and releases and waives any claims against Beyond the Bell Inc., its agents and employees,
for any damages to persons or properties, whether the result of negligence, breach of warranty or otherwise. The
undersigned further agrees to hold Beyond the Bell Inc., its agents and employees, harmless, for any injury to other
persons or property caused by participant’s involvement in this activity. Furthermore, I hereby agree to release and hold
harmless Beyond the Bell Inc. from any claim brought by a third party due to my participation in this activity. I understand
that my child or I may be photographed and give permission for photographs to be used to publicize activities for the
Beyond the Bell program. This agreement shall be effective and binding upon the parties hereto for the activities indicated.
If I am signing this agreement of behalf of a minor child, I understand that the foregoing agreements and waivers shall
apply equally to the child. Thus parties hereto acknowledge having read and understood this agreement.
beyondthebelldaycamp.com [email protected] 707-631-3993
www.beyondthebelldaycamp.com
Attendance and Permission From~ (please fill out front and back of this form!)
Child’s Name: _____________________________________________________________
Please check the option below that your child will be attending camp:

Full Summer – 5 days per week all summer June 15th-August 14th 2015

4 days per week ~ which days__________________________________________

3 days per week ~ which days__________________________________________

2 days per week~ which days__________________________________________

1 day per week ~ which day___________________________________________

Random Days ~ please include a monthly schedule of days attending

Payment Schedule:
IF YOU PAY IN FULL BY 4/31/15 for the whole summer you will receive a 10% discount.
. A 10% sibling discount is available. Fees listed below are for the whole summer:
Full Summer $1800(s) ($1620 if paid by 4/31)
Payments… Due May 15th $800, June 15th $500 July 15th $500
4 days per week $1620($1458 if paid by 4/31)
Payments… Due May 15th $620, June 15th $500 July 15th $500
3 days per week $ 1215 ($1094 if paid by 4/31)
Payments… Due May 15th $415, June 15th $400 July 15th $400
2 days per week $ $810($729 if paid by 4/31)
Payments… Due May 15th $310, June 15th $250 July 15th $250
1 day per week $405($365 if paid by 4/31)
Payments… Due May 15th $150, June 15th $150 July 15th $105
Various days throughout the summer are an option at $45 per day. (10% discount if paid by 4/31)
beyondthebelldaycamp.com [email protected] 707-631-3993
www.beyondthebelldaycamp.com
On going classes kids have the choice to sign up for
Multiple activities will always be offered, (3 different activities going at a time)
MONDAYS: SWIMMING AND SPORTS CAMPS
TUESDAYS: CHALLENGE COURSE, LIBRARY, Other Classes TBA
WEDNESDAY: HIKING AND FIELD TRIPS
THURSDAYS: Pottery, ART, CHALLENGE COURSE, Karate, Other Classes TBA
FRIDAY: PARK DAY, (Bikes, Kick Ball against Kid Camp, Gym Games,) Movie afternoon
Beyond the Bell~Summer Permission Form
Sun Screen and Bug Spray:
I will allow Beyond the Bell staff to apply sunscreen (supplied only by me) and Bug Spray
(supplied only by me) to my child prior to outside play.
__________________________________
Signature
________________
Date
Illness Policy
I will not allow my child to attend if he/she becomes exposed to any contagious disease, or if,
for any reason, I do not consider my child to be in good physical condition.
_____________________________________________________________
 Signature of Parent or Guardian
Acknowledgment of Policies & Procedures:
I have read and understood the Policies & Procedures of Beyond the Bell Summer Camp as well
as payment requirements and attendance cancellations.
Dated: ___________________
By: _____________________________
Signature of Parent or Guardian
beyondthebelldaycamp.com [email protected] 707-631-3993