Summer Camp Registration Form

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Summer Camp at LWF is for children aged 5-12 years.

Registration fee of $100 is due to hold your spot in the program. If you have NOT paid this fee, your spot is not guaranteed.
Tuition is $150 per week. We ONLY offer full-time care in Summer Camp.
Hours of care are Monday-Friday from 7:00 a.m.-6:00 p.m.
A copy of immunization records for each child is REQUIRED by the first day of attendance.
Meals are NOT provided. You will need to pack breakfast, lunch, and an afternoon snack.

172 Gunnell Road
Georgetown, KY 40324

If you have any questions, please contact Jessalynn Cornett at director@lwfchildcare.com or 502-642-6906.

Email *

Child's Full Name *

Child's Nickname

Please list expected drop off and pick up times. Hours of operation are from 7:00 a.m. - 6:00 p.m. *

Child's Gender *

Female

Male

Address *

Birthdate of Child *

YYYY

Guardian 1 Name *

Guardian 1 Email Address *

Guardian 1 Cell Phone *

Does this number accept text messages? *

Yes

Guardian 1 Work Phone *

Guardian 1 Employer *

Guardian 2 Name *

Guardian 2 Email Address *

Guardian 2 Cell Phone *

Does this number accept text messages? *

Yes

Guardian 2 Work Phone *

Guardian 2 Employer *

Child's Information

Does your child have any fears? *

If your child is upset, what methods work best to calm him/her? *

Does your child have any allergies? If so, please list them. *

Does your child have an epidural-pen? *

Does your child have any other emergency medication/treatments (inhaler, etc.) that will be kept on them while at our facility? *

Does your child have any dietary restrictions? *

Does your child have any special needs? *

Physician's Name and Phone Number *

Preferred Hospital and Phone Number (Note: This is for state regulations. Answering "closest hospital" is not sufficient. Should a true emergency arise, your child will receive the quickest care possible.) *

Is there any other information we should know about your child? *

EMERGENCY CONTACT INFORMATION

In case of emergency and we are unable to reach the parents/guardians, please list the information of your child's emergency contact. The following is a list of people that the childcare staff may release your child into their custody. I understand that anyone on this list may be required to show photo identification before staff releases my child.

Emergency Contact 1 Name *

Emergency Contact 1 Birthdate *

YYYY

Emergency Contact 1 Relationship To Child *

Emergency Contact 1 Phone Number *

Emergency Contact 2 Name *

Emergency Contact 2 Birthdate *

YYYY

Emergency Contact 2 Relationship To Child *

Emergency Contact 2 Phone Number *

Emergency Contact 3 Name *

Emergency Contact 3 Birthdate *

YYYY

Emergency Contact 3 Relationship To Child *

Emergency Contact 3 Phone Number *

PERMISSION IN CASE OF MEDICAL EMERGENCY: In the case of sickness or in the event my child is injured while receiving care at Living Waters Fellowship, my permission is granted for any staff member to administer treatment or obtain necessary medical attention to stabilize my child. *

PERMISSION FOR USE OF SUNSCREEN: I grant permission for sunscreen to be applied to my child as needed. *

PERMISSION TO VIDEO, PHOTO, AND/OR RECORD: I grant permission as the parent/legal guardian to the LWF Program to use my child's photograph, video recording, and/or voice in any way that would reasonably portray the activities at the program. This includes pictures taken in the classroom or at school programs. This also includes pictures or videos (with no names) that we may post on social media and our website. I further release the staff from any damages in using my child's photograph, video recording, and/or voice. *

ASSUMPTION OF RISK, WAIVER, AND RELEASE OF LIABILITY: I grant permission for said child to participate in the activities, programs, parties and/or other functions at this program. I release Living Waters Fellowship and its childcare program of any liability including, but not limited to the following: bodily injury including, but not limited to permanent disability, paralysis, and death. These risks may result from a variety of circumstances including the misuse of equipment or facilities. I agree to comply with all rules, policies, and regulations of the program. I understand that LWF reserves the right to revoke or terminate my use of the program for any violation of rules, policies, or regulations. I hereby release, waive, discharge, and hold harmless the LWF program and all employees past or present from any claims, suits, liabilities, judgements, costs, and expenses for any property damage, loss or theft, personal injury or illness, death, or other loss arising from the LWF program. I hereby waive any protections afforded by any statue or law in any jurisdiction whose purpose and/or effect is to provide that a general release shall not extend to claims, material or otherwise which the person giving the release does not know or suspect to exist at the time of executing the release. I am releasing unknown future claims. I agree to pay for any and all damages to any property or equipment as a result of my or my family’s willful actions, neglect, or recklessness and agree to be held liable for all such costs associated with such damages.I understand that I am solely responsible for any medical, health, or personal injury costs relating to my use of the LWF program and its facilities. I understand that I am strongly encouraged to have a medical physical exam and purchase health insurance prior to my use of the program. I agree to be bound by all the terms of the assumption of risk, waiver, and release from liability. I give my consent for participation in the program. *

RELEASE TO PARTICIPATE: I give permission for my child to go (walk) to other areas on the facility premises. My child is also allowed to participate in programming and activities provided by staff from the licensed child care program or school personnel upon the discretion of the staff. Supervision must be maintained by a qualified adult staff at all times. Programming options on the premises may include but is not limited to: the cafeteria, playground, Chapel, Music Room, parking lot, large open field by the building, etc. *

I verify that all of the information provided in this form is accurate and truthful. *

Tuition and Other Related Policies

Tuition is still required for holidays. Please check the website for the holiday closure schedule.

Should your child be ill and unable to attend, tuition is still required.

The hours of care are 7:00 a.m.-6:00 p.m.

A $100 enrollment fee is required to reserve your child's spot in the program.

Tuition is $150 per week.

Tuition is due every Friday. Failure to have tuition paid by the Friday drop-off time will mean your child cannot stay or participate in the program. This means tuition will always be paid for the upcoming week. Invoices are sent every Thursday by 5:00 p.m.

A 14 day notice is required to withdraw from the program. If notice is not given, you are required to pay the tuition for the next two weeks.

A late fee of $1 per minute the child remains past 6:00 p.m. This fee is due at the time of pick-up and should be given to the program supervisor. If there is an emergency, please communicate with staff. I understand and agree to these tuition and fees.

*Always check the Parent's Guide for updated policies and information. All families are held to those policies.

A copy of your responses will be emailed to the address you provided.

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