APPLICATION OF ENROLLMENT- CAMP DISCOVERY

Child's Name: _________________________________________________ Date:____ /_____ /_____
Child prefers to be called: ________________________________________
Date of Birth: ____________ Home Phone: ______________ Cell or Pagers: ______________________ 
Home Address: ______________________________________ City: ____________ Zip Code:_______ 

Parent's Names: _____________________________________________________________________

Mother' s occupation:_____________________________ 
Place of Business: _______________________________________Business Phone: ________________
Business Address: ____________________________________ City: ____________ Zip Code:_______
Social Security Number:_________________ Texas Driver's License No.: ________________   

Father's Occupation: ______________________________ 
Place of Business: _______________________________________Business Phone: ________________
Business Address: ____________________________________ City: ____________ Zip Code:_______
Social Security Number:_________________ Texas Driver's License No.: ________________   

The Discovery School was recommended by:__________________________________________________
Are parents living together, separated or divorced:_____________________________________________
If separated or divorced, who has custody of the child:_________________________________________
Please list home address and phone number of other parent:______________________________________
___________________________________________________________________________________
Hours of enrollment (please note the hours of drop off and pick up and if you will need after school care): 
___________________________________________________________________________________
___________________________________________________________________________________

In case of an emergency and parents cannot be reached, please contact one of the following people: 
Please list local friends and relatives:

Name:__________________________________
Address:__________________________________________ City:________________ Zip Code:______
Phone: Work:________________________ Home:______________________

Name:__________________________________
Address:__________________________________________ City:________________ Zip Code:______
Phone: Work:________________________ Home:______________________

Does your child have any medical problems we should be aware of? (i.e. allergies to food or insects, hay fever,
asthma, existing illnesses, previous serious illness or injuries, hospitalizations during the past 12 months or any 
medications prescribed for long term, continuous illness, etc..)

___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

I agree to provide a current record of immunizations for my child to the director of The Children's Discovery 
Center/Camp Discovery PRIOR to the first day of enrollment, along with this completed application. I understand Camp Discovery observes the following holiday: July 3th-the Friday before Independence Day. I understand that tuition is 
not prorated for this holiday. I have received a copy of A Parent's Guide to Day Care published by the Department of 
Human Resources. (Effective September 1985).

I understand when I sign below that I am acknowledging the policies stated within this document and I agree to abide 
by them for so long as my child is enrolled in Children's Discovery Center/Camp Discovery.

Signature of Parent or Guardian: _________________________________Date:____________

AUTHORIZATION FOR THE RELEASE OF YOUR CHILD

When my child, _____________, is brought to The Discovery School or Children's Discovery Center, I agree to
always leave him/her with a staff member and acknowledge the arrival with that staff member ( do not let your
child in the gate and leave without talking to a staff member ). The child shall only be released to the parents or
people listed in the space below. I agree to notify the center if anyone other than these people will be picking up 
my child.

Names of friends or relatives allowed to pick up my child when in the care of The Discovery School or Children's
Discovery Center:

___________________________________________________________________________________
___________________________________________________________________________________

AUTHORIZATION TO LEAVE FACILITY

 I hereby give my consent for my child, _________________, to leave Children's Discovery Center/Camp Discovery to participate in field trips and to travel to and from such field trips in the school's van, or walking if the field trip is in the neighborhood. I understand that the field trips will be daily and ongoing through my child's day at Camp Discovery.

HEALTH STATEMENT

My child, ____________________, has been examined by a licensed physician within the past year or has been examined in a clinic or is enrolled in an on-going health program. My child is physically able to take part in the program provided by Children's Discovery Center/Camp Discovery. My child will continue to receive required immunizations while enrolled in this facility agree to submit all immunization records to the Director for photocopying PRIOR to enrollment realize that I may not be permitted to enroll without immunization records. The date of his/her last physical examination:_____________

EMERGENCY MEDICAL AUTHORIZATION

n the event I cannot be reached to make arrangements for emergency medical treatment for my child: _________________, I hereby authorize any staff member of The Discovery School or Children's Discovery Center or other capable adult or  emergency medical attendant to transport my child to the nearest medical facility and request any necessary medical  treatment in the event of an emergency. I request that he/she is taken to the following medical centers, if possible, for  treatment: ____________________________________________________________________.

Physician's Name:_________________________________ Telephone: _____________________
Address:________________________________________________
The hospital or emergency facility I prefer is:
Name:_________________________________________ Telephone:________________

Signature of Parent or Guardian: ___________________________________Date:__________

 

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