* required
*Child's first name    *Last name
*Birth date   Age Favorite color   Favorite flavor
  Food(s) child dislikes and will not eat
*Parents' names
*Address   *City/State   *Zip
*Home phone   Cell or work
*Emergency contact name     *Phone
  Email address

* Select one of the following:
Wk 1 June 6-9 Ages 5, 6, 7

Four-day camp, Monday to Thursday
Camp Cost:  $200
($100 deposit, $100 due on first day of camp)

Includes: Lunch, cooking classes, limousine ride, swim day at Country Club, crafts, etiquette/manners class, and much more.

Penalties: $100.00 cancellation fee.
Wk 2 June 13-16 Ages 5, 6, 7
Wk 3 June 20-23 Ages 8, 9, 10
Wk 4 June 27-30 Ages 5, 6, 7
Wk 5 July 4-7 Ages 5, 6, 7
Wk 6 July 11-14 Ages 8, 9, 10
Wk 7 July 18-21 Ages 8, 9, 10
Wk 8 July 25-28 Ages 5, 6, 7
Wk 9 Aug 1-4 Ages 8, 9, 10

Wk 10 Aug 8-11 Ages 5, 6, 7

Drop-off time: 10:00 a.m.      Pick-up time: 3:00 p.m.
Wednesday: Drop-off 10:30 and pick-up 3:00 at Country Club
$10.00 fee per day will be charged for late pick-up.

Chelsea's Tea Room & Boutique Release

*Is your child allergic to anything which might be encountered this week?
  Food, paints, glues...
  Explain
  Other
 		 No Yes
*Is your child on any special medication or diet?
  Explain
 		 No Yes
*Are there any special medical problems which would affect her activities this week?
  Explain
  Check any of these which apply:
   Diabetes  Epilepsy  Hyperactivity  Asthma  Hayfever
  Explain other problems:
 		 No Yes
*Are there any restrictions on your child's activities? (Include swimming)
  Explain
 		 No Yes
*Can your child go off the diving board?
 		 No Yes
*My child has permission to travel to lunch via limousine.
 		 No Yes
  Anything else we should know about your child?
 
*Doctor's name   *Phone
  Insurance Co.   Group #

ACKNOWLEDGEMENT
* By checking this box, I, as the parent or guardian of the child described above, acknowledge and agree to the following:  In case of medical emergency, after every reasonable effort has been made to contact parent or guardian, I hereby give permission to Chelsea's Tea Room & Boutique to secure necessary treatment for the child herein described. I have not been given a guarantee of the results of examination or treatment. I approve all above activities.

I also give my permission for pictures to be taken and shared with other families of the same week. Pictures may be used at Chelsea's Tea Room & Boutique and at Chelseas.org.

*Name of parent or legal guardian completing this form
*Email address for confirmation of registration