* 6450 Harrison Ridge Blvd Indianapolis, IN 46236

É (317) 418-1975 | (317) 823-7871

Registration Form

Last Name

First Name

Midle Initial

Gender

Father's Name

Mother's Name

Guardian's Name

Address

City

State

Zip

Parents work phone number

Parents cell phone number

Home phone number

E-mail Address

Date of birth

School

Grade

Township

Current teacher

Is your child currently in a Spanish immersion program?

Yes

What is your child's level of Spanish?

If so, what level / year?

Beginner (No Experience)

Intermediate (Some Understanding)

Advanced (Communicates)

Would you like a camp shirt for your child?

Yes

If yes, what size shirt?

Emergency contact name:

Emergency contact phone number:

Does your child have any disabilities, handicaps, present injuries or limitations, allergies, heart conditions, history of respiratory illness or any other significant conditions?

Yes

If yes, please list the conditions.

If you wish to have a family doctor contacted in case of an emergency, please provide name and phone number:

If your child needs to take any medications during the camp, please list the name of the medication and the time it is to be administered.

Which camp are you registering for?

I, the parent/guardian of the above named individual, understand and accept that participating in the camps listed above may involve risk of physical injury. I understand that the athletic activities and the activities using tools such as hammers, nails, etc, in the camps may result in injury; and/or accidents might happen while on fieldtrips. I further acknowledge that the camps listed above are administered by Mr. Jerome Omar Lahlou, who is conducting these camps, as a private entity, independently from Forest Glen Elementary and MSDLT. I hereby agree to and accept any and all liability for any damage caused by my child/ren while on the premises for the purpose of attending the camp and hold harmless the camp, Jerome Omar Lahlou, the instructors, and MSDLT for any injury sustained by the child including physical injury due to the negligence of any instructor while performing his or her duties during the camps.

I have read and agree to the above stated terms of acceptance.

Any questions or comments.