Englewood Christian Church

4316 Barnes Road

Jacksonville, FL 32207
(904) 737-5669 TLC or
(904) 733-2356 ECC
(904) 733-9096 Fax

Power Challengers Summer Day Camp 2012

Application for Admission
K-8th Grade
CHILD INFORMATION

Childs Name_______________________Birth Date___________Grade Completed_________

Sex_____Place of Birth__________________________ T-Shirt size preference_______
Your E-mail address______________________________________________________
Chose ONE of the following:
___I will be paying full-time tuition weekly ($120/week).
*** Second child full-time tuition weekly ($96/week).
___I will be paying full-time tuition weekly for 6th-8th ($85/week).
*** If you pay for the entire summer up front (8 weeks; 2 weeks vacation) before
June 1, is it ONLY $100/week.
***Registration fee is $25 until February 28th; $50 after February 28.
* $ 25 for second child

___I will be paying daily elementary tuition ($32/day)

___I will be paying daily middle school tuition ($25/day)
I understand by checking one of the above I agree to pay this amount on the first day of the
week every week and if my payment is not received on time a late payment of $10 per day
will be due ____ (Initials).
I understand that if my child is not in attendance I will be required to make a payment in
order to hold their spot, with the exception of two weeks of vacation per year.
____ (Initials).
PARENT INFORMATION
1. Father_______________________ Daytime #_____________Home Phone________________
Address________________________________ZIP__________Work Phone_________________
Occupation____________________Employer_______________Cell# _____________________
2. Mother_____________________Daytime #_______________Home Phone________________
Address________________________________ZIP___________Work Phone________________
Occupation________________________Employer__________________Cell# ______________
3. Additional people living in household.
Name____________________________Age & Grade______________School_______________
Name____________________________Age & Grade______________School_______________
(Turn over and complete the other side)
4. Child making application lives with_________________________Relationship_____________

5. If the legal guardian of the child is not one of the parents, please supply the following information.
Name of legal Guardian ___________________________Relationship______________________
Address________________________________________________Home Phone_____________
Occupation____________________Employer__________________Work Phone_____________
6. Persons to contact in case of emergency, when parent or legal guardian cannot be reached:
Name__________________________Relationship___________________Phone_____________
Name__________________________Relationship___________________Phone_____________
HEALTH INFORMATION
Please indicate below any medical information necessary for the care of your child:
______________________________________________________________________________
______________________________________________________________________________
Child=s Physician______________________________________________Phone_____________
*** How did you hear about PCMs Summer Day Camp?
______________________________
_____________________________________________________________________________
__
STATEMENT OF RESPONSIBILITY
In making application for enrollment at Power Challengers Day Camp, I agree to support the Christian dress code and
conduct codes of the center. If my child is accepted, I agree to support through attendance and participation, the various activities of
the camp including teacher conferences, informational meetings, and other special events.
I also understand that this application cannot be considered without the registration fee. I also understand that the registration
fee cannot be refunded. This fee goes to initial costs of setting up camp, such as field trip bookings, supplies, snacks, etc.
ECC & The Total Learning Center reserve the right to refuse any application or dismiss any child at any time for any reason it
deems necessary. ECC and TLC do not discriminate on the basis of race, color, national, or ethnic origin.
If legal action is required to collect tuition or fees, the undersigned will pay any fees which are incurred.

Fathers Signature___________________________________Date____________________
Mothers Signature__________________________________Date____________________
Guardians Signature_________________________________Date____________________
______________________________________________________________________________
OFFICE USE ONLY
Date Received_________________Application Complete________Registration Fee Paid________Amount Paid_________Cash_____Check____
Check #_______Application Accepted ____Yes ____No If no, Why?_____________________ Number on Waiting List_________

POWER CHALLENGERS MINISTRIES

DISCIPLINE POLICY
1. Our permission is granted to the director and workers to exercise discipline in
accordance with one of the following measures:
a. Time out.
b. Privileges taken away such as play time or a certain activity.
c. A special activity may be assigned.
2. We understand that if the above mentioned measures are not successful, we
will be called by the Power Challengers Program to discuss further action, or
to remove our child from the premises that day.
3. We understand that if a continual behavior problem arises that cannot be
resolved our child will be subject to removal from the program.
4. We will cooperate fully with the Power Challengers director and workers by
encouraging our child to be obedient, respectful and cooperative.
We would appreciate the cooperation of all parents and guardians. Please help
us to make Power Challengers Ministries a safe and enjoyable environment for
all involved.
Children will not be subjected to discipline that is severe, humiliating, frightening,
or associated with food, rest or toileting. Spanking or any other form of physical
punishment is prohibited by all child care personnel.
Signed _________________________________ Date _____________
I have received and read the above discipline policy and agree to the terms
stated.

AUTHORIZATION FOR STUDENT RELEASE

STUDENT NAME: ___________________________
GRADE & SCHOOL: ____________________
Below please list ALL people who are authorized to pick up your child from Power Challengers

Program including your name:

1.
2.
3.
4.
5.
6.
7.
8.
9.

_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________

I give authorization to the people listed to remove my child from the

Power Challengers Program at Englewood Christian Church.
Parent Signature: ________________________________
Date: _____________________
* These people can pick your child up on any given day
without us calling and informing you.