Open Mind School Summer Camp Registration Form
We welcome students from our community to join the fun at Open Mind School. This schedule is filled with meaningful project based learning, music, sensory motor play, and art enrichment services, yoga movement, etc. Siblings join free!

Registration Guidelines and Policies
-Complete and submit the registration form
- Payment must be made upon registration, unless you are applying for a scholarship.

The Open Mind School admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in administration of its educational policies, admissions policies, scholarship and loan programs, and athletic and other school-administered programs.
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Student's Full Name *
Student's DOB *
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Student Snapshot (likes, dislikes, interests, any areas for support needs, etc.) *
Allergies *
Second Student's Full Name (if applicable)
Student's DOB
MM
/
DD
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YYYY
Second Student Snapshot (likes, dislikes, interests, any areas for support needs, etc.)
Second Student Allergies
Third Student's Full Name (if applicable)
Student's DOB
MM
/
DD
/
YYYY
Third Student Snapshot (likes, dislikes, interests, any areas for support needs, etc.)
Third Student Allergies
Guardian's Full Name *
Guardian's Phone Number *
Guardian's Email Address *
Guardian #2 Full Name (if applicable)
Guardian #2 Phone Number (if applicable)
Guardian #2 Email Address (if applicable)
Summer Camp Dates: 
Please list your desired dates for participation in summer camp below. 
 *
Please enter the names and phone numbers of the people authorized to pick your child up from Open Mind. *
Please enter the name and phone number of two emergency contacts. *
Open Mind has permission to take photos, video, audio recordings on my child while at summer camp. I understand and consent to the use of these images, audio, etc for purposes Open Minds deems appropriate including but not limited to educational or promotional marketing purposes. *
My child has permission to be transported by an Open Mind School vehicle and to participate in all Open Mind program activities and related field trips. *
In the case that your child becomes ill during the program, you will be contacted as soon as possible. If the parent or guardian  is unable to be reached, the child’s emergency contact will be notified. It is the responsibility of the parents or guardians to  arrange for the child to be picked up from the center as soon as possible. *
Required
In the case that your child or anyone in the immediate household of the child develops a reportable communicable  disease as defined by the State Board of Health, it is the responsibility of the parent to notify Open Mind School within 24 hours or the next business day in order for Open Mind School to take proper action, except in the case of life-threatening diseases which must be  reported immediately. *
Required
My signature authorizes the management and staff of Open Mind School to act for me according to their best  judgment in the event of a medical emergency and/or routine medical care. I/we grant permission for emergency medical  treatment and/or routine medical care by Open Mind School staff, a rescue squad, or private physician and/or hospital or emergency  health care facility staff, under the same circumstances as above, if needed. Any such action will be taken in the best interest of  my child and will be reported to me/us as soon as possible. My signature waives and/or releases Open Mind School from any and all liability and/or financial responsibility for any medical expenses incurred. *
Required
I understand that Open Mind School and its employees, volunteers, counselors, teachers, trainers, representatives, and therapists assume no responsibility for loss, damage, illness or injury to  person or property that I or my minor child(ren) or ward(s), if applicable, may sustain as a result of participation in any activities, programs, events, or classes at Open Mind School's Summer Programs *
Required
By checking this box, I am giving my signature and authorizing the above. *
Required
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