Little Crusaders Summer Program Registration

Please complete the form below. Required fields marked with an asterisk *

*** For Current Pre-K3 and Pre-K4 Students who turn 5 after June 1st ***

Child First Name*

Answer required for "Child First Name"

Child Last Name*

Answer required for "Child Last Name"

Gender*

Answer required for "Gender"

Male

Female

Date of Birth*

Answer required for "Date of Birth"

Weeks Attending Summer Program*

Answer required for "Weeks Attending Summer Program"

Week 1 (June 1st - June 5th)

Week 2 (June 8th - June 12th)

Week 3 (June 15th - June 19th)

Week 4 (June 22nd - June 26th)

Week 5 (July 6th - July 10th)

Week 6 (July 13th - July 17th)

T-Shirt Size*

Answer required for "T-Shirt Size"

Will this child be enrolled at St. Matthew for 26-27?*

Answer required for "Will this child be enrolled at St. Matthew for 26-27?"

Yes

List any information concerning your child’s medical or physical condition (medications, allergies, ailments, etc.) that staff should know about (attach additional info is necessary). If no conditions, please write NONE.

Answer required for "List any information concerning your child’s medical or physical condition (medications, allergies, ailments, etc.) that staff should know about (attach additional info is necessary). If no conditions, please write NONE."

Medical Information File Upload (if necessary)

Answer required for "Medical Information File Upload (if necessary)"

Choose a file or drag it here.

RELEASE OF LIABILITY: I hereby consent to the participation by my child in the event described above and release my child to St. Matthew the Apostle's care for the Little Crusaders Summer Program. I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity, related accidents, and physical injury due to transportation related accidents. By signing this Liability/Waiver Form, I expressly assume all risks of the child participating in the activities, whether such risks are known or unknown to me at this time. I further release this organization and its leaders, employees, volunteers, and agents from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of the child’s or my family or estate, heirs, representatives, or assigns may have against this organization or its leaders, employees, volunteers, or agents.

I further agree to indemnify and hold harmless this organization and its leaders, employees, volunteers, or agents from any and all claims arising as a result of injury or illness of my child during such activities.

Release of Liability*

Answer required for "Release of Liability"

Yes

MEDICAL & EMERGENCY TREATMENT: I recognize that there may be occasions where the child named above may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of this organization to seek and secure any needed medical attention or treatment for the child named above including hospitalization, if in the agent’s opinion such need arises. In doing so I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment. I give permission for the SMA Little Crusaders Summer Program Nurse and designated adult staff members to give over the counter medications as needed. I give permission to transport the child named above to a medical treatment center in a non-emergency vehicle in a medical emergency situation.

Medical and Emergency Treatment*

Answer required for "Medical and Emergency Treatment"

Yes

MEDIA PUBLICATIONS: Enrolling a student into the St. Matthew the Apostle Little Crusaders Summer Program constitutes the consent of his parents/guardians for the student’s name, voice or likeness to be used in news publications, audio-visuals, and other electronic transmissions including the St. Matthew the Apostle website.

Media Publications*

Answer required for "Media Publications"

Yes

Little Crusaders Summer Program Handbook

I have read and agree to the Little Crusaders Summer Program Handbook Policies (linked above)*

Answer required for "I have read and agree to the Little Crusaders Summer Program Handbook Policies (linked above)"

Yes

Charlie's Law

I have read and acknowledge the Charlie's Law document linked above*

Answer required for "I have read and acknowledge the Charlie's Law document linked above"

Yes

Signature*

Signature Required

Parent Guardian 1

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Answer required for "Email"

Phone Number

Number Required

Relation to Child*

Answer required for "Relation to Child"

Mother

Father

Other:

Is Your Family Parishioners of SMA Parish?*

Answer required for "Is Your Family Parishioners of SMA Parish?"

Yes

Parent / Guardian 2

First Name

Answer required for "First Name"

Last Name

Answer required for "Last Name"

Answer required for "Email"

Phone Number

Number Required

Emergency Contact

Other than guardians or adults allowed to pick up children

First Name

Answer required for "First Name"

Last Name

Answer required for "Last Name"

Relation to Child

Answer required for "Relation to Child"

Phone Number

Number Required

Family Medical Information

Name of Provider

Answer required for "Name of Provider"

Provider's Address

Answer required for "Provider's Address"

Policy Holder's Name

Answer required for "Policy Holder's Name"

Policy Group Number

Answer required for "Policy Group Number"

Name of Family Physician

Answer required for "Name of Family Physician"

Physician's Phone Number

Number Required

Physician Address

Street Address

Answer required for "Street Address"

City

Answer required for "City"

Zip/Postal

Answer required for "Zip/Postal"

Little Crusaders Summer Program Rates

1 Week	$250
2 Weeks	$490
3 Weeks	$720
4 Weeks	$940
5 Weeks	$1150
6 Weeks	$1350

Registration Fee

There will be a $60 registration fee per child due at the time of registration

Please continue with payment on our online store after clicking submit.

Please fix the highlighted areas below before submitting.

Little Crusaders Summer Program Registration