DAY CAMP REQUEST

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COVID-19 Updates
Online Summer Camp
On-Site Summer Camps
Camp Instructor

Home
COVID-19 Updates
Online Summer Camp
On-Site Summer Camps
Camp Instructor

Champion Art Day Camp Request

* Indicates required field

Request Camp Date: *

Camp services on WPCSS Teacher Workdays, Professional Development days, Parents Conference days, Certain Holidays

#1 Camper's Name *

First

Last

#1 Camper's Date of Birth *

#2 Camper's Name (optional) *

First

Last

#2 Camper's Date of Birth (optional) *

Parent/Caregiver's Name *

First

Last

Phone Number *

Email *

Add-on (choose more than one) *

None Champion Lunch (Pizza & Juice or Chinese Food & Juice) - $5/day/student Morning Extended Care (8am - 9am) - $5/day/student *free for Champion After School Students Afternoon Extended Care: Mandarin or Self-study (4pm - 6pm) - $10/day/student *free for Champion After School students

Allergy or other medical information (You may store your child's medication at Champion office and take it back when checking out Champion Camp.) *

Check all that apply *Information from CDC:Interim US Guidance for Risk Assessment and Public Health Management of Persons with Potential 2019 Novel Coronavirus (COVID-19) Exposure in Travel-associated or Community Settings *

My child has living in the same household or close contact with patients with confirmed COVID-19 infection for the past 14 days. My child has traveled to COVID-19 outbreak area for the previous 14 days. My child has living in the same household or has close contact with people who have back to COVID-19 outbreak areas for the past 14 days. My child has met any symptom for the past 5 days: measured fever, cough, or difficulty breathing. None of these apply

Acknowledgement and Waiver *

I authorize and grant permission for a representative of Champion Camp to treat minor injuries including scrapes, small cuts, splinters, and insect bites. I authorize and grant permission for a representative of Champion Camp to obtain emergency medical care from any licensed physician or hospital and/or medical clinic should my child become ill or injured. I therefore freely and voluntarily execute this release with such knowledge, assume the risk of personal injury and/or property loss arising from or in any way connected with participation in any programs offered by said child care center. I hereby release and discharge said child care center and any and all agents from any liability, claim, cause of action, demand or damages from injury or damages of any kind to my child or my property as a result of participation in the programs of Champion Camp. I grant permission and understand that photos and other images taken during this event could be used in print advertisement and other forms of media. I understand that should my child become a disruptive force during the educational program that the instructor may choose to release him/her from the program with no refund.

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