Summer Camp - Extended Day Center Program
June 7, 2021 - July 23, 2021
6:30 am - 5:30 pm
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There are 2 locations available. (Please check 1 location) *
Registration Information:
* Child must be in grades K-6 during 2020-2021 school year
* $100 non-refundable registration fee required with application
* Submit, mail or deliver registration form and fee to 310 SE 8th Street, Evansville IN 47713
* $100 Weekly Fee (Due on Monday of EACH week)
* A 7 week commitment with exception of a 1 week scheduled vacation

Vacation information:
Clear selection
 Our vacation will be the week of: (full week only)
Please check one: Breakfast and Lunch will be provided by the Food Summer Lunch Program. *
T-Shirt size: *
Child's Information
Child's Name (First, Middle, and Last) *
Child's Date of Birth *
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Child's Grade *
Child's Home Address (Street, City, State, and Zip) *
Child's Home Phone or Cell Number *
Child's Home School *
Medical
Child's Allergies
Medical Condition(s)
Parent Information
Please check the box(es) below to indicate who has legal custody
Legal Custody
Parent/Guardian #1 - Name (First and Last) *
Parent/Guardian #1 - Address (Street, City, State, and Zip) *
Parent/Guardian #1 - Home or Cell Phone *
Parent/Guardian #1 Workplace, Phone number and when Workday Ends *
Parent/Guardian #2 - Name (First and Last)
Parent/Guardian #2 - Address (Street, City, State, and Zip)
Parent/Guardian #2 - Home or Cell Phone
Parent/Guardian #2 Workplace, Phone number and when Workday Ends
Email Address REQUIRED *
In Case of Emergency
When parents cannot be reached, the individuals listed below may be called and/or authorized to pick up child.
Emergency Contact #1 - Name and Relationship *
Emergency Contact #1 Home and/or Cell Phone *
Emergency Contact #2 - Name and Relationship
Emergency Contact #2 Home and/or Cell Phone
My child may NOT be released to the following individuals:
Payment and Attendance (Your typed signature below is agreement of this information)
I agree to pay my summer camp fees on each Monday of the week that my child will attend. I understand that my registration can be cancelled prior to April 5th without any further financial obligations and deposits are non-refundable.  After April 5th, if my child cannot attend 7 weeks, with the exception of 1 week vacation, then I will be responsible for paying the remaining balance of my 7 week commitment.  If payment is not received, the my account will be sent to collections. I understand the school reserves the right, in extreme circumstances, to terminate the enrollment of any child if the coordinator, Director and/or the Associate Superintendent determines that continued attendance would not be in the best interest of either my child or the school.  In case of an emergency involving my child, it is the policy of EVSC to give first aid treatment while contacting the parent/guardian for further instructions.  In the event the parent/guardian cannot be contacted, school officials will contact 911.  If I am late picking up my child, then a late fee will be charged to my account.  If my child has not been picked up at the end of the summer camp day, and my emergency contact designee cannot be reached, then the Department of Child Services will be contacted.
Parent Signature *
Date *
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