* 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 for daily pictures

* Select one of the following:
Wk 1 June 9-13 Ages 5, 6, 7

Camp Cost:  $225
$250.00 after May 1, 2008
(paid at time of registration)
Includes: all activities, lunches and snacks

Penalties: $25 charge for returned checks, $100.00 cancellation fee.

$10.00 fee per day will be charged for late pick-up.
Wk 2 June 16-20 Ages 8, 9, 10
Wk 3 June 23-27 Ages 5, 6, 7
CLOSED Wk 4 June 30-July 4 Ages 8, 9, 10
Wk 5 July 7-11 Ages 5, 6, 7
Wk 6 July 14-18 Ages 8, 9, 10
Wk 7 July 21-25 Ages 5, 6, 7
Wk 8 July 28-Aug 1 Ages 8, 9, 10
Wk 9 Aug 4-8 Ages 5, 6, 7

Wk 10 Aug 11-15 Teen Week 11, 12, 13

Parents are welcome to attend all activities. We will
be walking to other businesses in Lincoln Court.
Grace will be said at lunch.

Drop-off time: 10:30 a.m.      Pick-up time: 3:00 p.m.
Thursday: Drop-off and pick-up at Shady Valley Country Club 4001 W. Park Row
 $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?
  Dogs, cats, 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 and bounce house)
  Explain
 		 No Yes
*Can your child go off the diving board?
 		 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.

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