Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Which weeks would you like to attend? *

Students must attend at least 4 weeks

All 10 Weeks (June 6-August 19)

All of June (June 6-July 1)

All of July (July 5-29)

All of August (August 1-19)

Session 1: June 6-10

Session 2: June 13-17

Session 3: June 20-24

Session 4: June 27-July 1

Session 5: July 5-8

Session 6: July 11-15

Session 7: July 18-22

Session 8: July 25-29

Session 9: August 1-5

Session 10: August 8-12

Session 11: August 15-19

Are you interested in our regular day camp or extended day camp?

Day Camp (7:00 AM-2:30 PM) $300/week

Extended Day Camp (7:00 AM-6:00 PM) $350/week

Parent 1 *

First Name

Last Name

Parent 1 Phone Number *

(###)

###

####

Parent 2

First Name

Last Name

Parent 2 Phone Number

(###)

###

####

Medical/ Personal Information *

Please check all that apply so that we can better assist your child. *Please note, Old School may not be able to accommodate certain needs. If you have questions about whether we are equipped to work with your child, please contact us at 713-510-3164.

Asthma

Allergies

ADHD/ ADD

Aspergers

Autism

Dyslexia

Dysgraphia

Behavioral Issues

Section 504 Accommodations

Special Education*

None

Emergency Contact 1 *

First Name

Last Name

Emergency Contact 1 Phone Number *

(###)

###

####

Play Release *

I hereby give permission for my child to use indoor and outdoor active play equipment.

I agree

Field Trip Release

I hereby give permission for my child to be transported in Building Blocks vehicles during an occasional field trip off campus. I understand that I am responsible for providing a booster seat if desired. For Summer 2022, we will most likely remain on campus for "in-house field trips."

I agree

Media Release *

I hereby give permission for my child to be photographed or videotaped for program events, brochures, newsletters, presentations for educational purposes, or social media updates.

I agree

Movie Permission *

I hereby give my child permission to occasionally watch a movie while at Old School. All movies will either be G or PG and only be screened as a fun activity for students on occasion.

I agree

Water Activities Permission *

I hereby give my child permission to participate in water activities. These include Slip N' Slides, sprinklers, water blasters, and kiddie pools filled with no more than 1 foot of water.

Option 1

Option 2

Medical Authorization & Permission to Treat *

I hereby grant Old School ASC permission to take whatever action in its judgement may be necessary in supplying emergency medical services to the named child. I understand that, consistent with the circumstances of the situation and available time, Old School ASC will make every effort to contact and follow the instructions of the parent or legal guardian. I hereby Agree that I will be solely responsible for and will pay promptly any expenses which may be incurred by Old School ASC in making emergency medical treatment to named child.

I agree