Discover Learning Center

Discover Learning Center Registration Form for Summer Camp 2017 http://www.discoverlearningcenterva.com/ Summer Camp Location: 3901 Fair Ridge Dr., Fairfax, Virginia 22033, on route 50, near Fairfax County PKW/286 Student Name: ______Grade: ______Parent/Guardian: ______Address: ______Phone (Home): ______(Cell): ______Email address: ______Emergency Contact (Name & Phone):______

Half/Full Day Summer Camp Sessions (Full Day = Monday to Friday, 8:30am to 5:30pm) (Half Day = Monday to Friday, 8:30am to 12:00pm) (Extended Care = Monday to Friday, 5:30pm to 6:30pm)

Session 1: 06/26/2017 to 06/30/2017 Session 2: 07/03/2015 to 07/14/2017 (No class on 7/4/2017) Session 3: 07/17/2017 to 07/28/2017 Session 4: 07/31/2017 to 08/11/2017 Session 5: 08/14/2017 to 08/25/2017

Session ($Half Day Price__ $Full Day Price) Select the classes below, to cycle the price in the table:

Rising Session 1 Session 1 Session 2 Session 2 Session 3 Session 3 Session 4 Session 4 Session 5 Session 5 Grade Half Day Full Day Half Day Full Day Half Day Full Day Half Day Full Day Half Day Full Day Price Price Price Price Price Price Price Price Price Price Rising 1st 235 360 400 600 430 660 430 660 430 660 Rising 2nd 235 360 400 600 430 660 430 660 430 660 Rising 3rd 235 360 400 600 430 660 430 660 430 660 Rising 4th 235 360 400 600 430 660 430 660 430 660 Rising 5th 235 360 400 600 430 660 430 660 430 660 Rising 6th 270 420 460 660 490 720 490 720 490 720 Rising 7th 270 420 460 660 490 720 490 720 490 720

Extended Care: Session 1 ($50), Session 2($90), Session 3($100), Session 4($100), Session 5($100)

Registration fee for summer camp: $30 per student, it is non-refundable Early Registration Discount by received the Registration form and Full Payment before 4/30/2017: -$30.00 per student, per Session Multiple Session discount: -$30.00, starting from the 2nd session for every session. Sibling Discount: -$30.00 for second child Late Registration will be charged after 6/5/2017: +$60.00 per student, per session Total payment: $ ______

Refund Policy: A full payment will reserve a seat in the selected session/sessions. A full refund will be issued if it is requested at least two weeks before the beginning of session/sessions, and the registration fee will be charged. There will be no refund after the session/sessions start. Registration fee is not refundable. If a refund request is made within two weeks prior to the beginning of the session/sessions, $100 withdraw fee will be charged.

PARENTAL RELEASE AND CONSENT FOR MEDICAL TREATMENT My child is enrolled in Discover Learning Center. I hereby release Discover Learning Center and its Director, staff and teachers from any and all liabilities for injuries to my child or damage property of my child due to activities outside classroom. I accept the full risk and responsibility for any damage or injury. I, the undersigned, am one of the parents of the minor named above. I know that I may not be available to personally authorize medical, dental, surgical care and hospitalization for said minor. I hereby give my consent and authorization for any emergency diagnostic procedure, medical, dental, surgical care and hospitalization that any health care provider so determined as advisable, in the best judgment of said health care provider including, but not limited to, any physician, dentist or hospital personnel providing health care to the minor. I agree to be responsible for the cost of the emergency medical treatment.

Health Insurance company ______, Insurance Policy # or HMO ______Medications List ______, Allergies List ______

______Parent Signature Date

Please make check payable to: Discover Learning Center Mail to: Discover Learning Center, P.O. Box 386, Great Falls, VA 22066 A confirmation email will be sent upon receipt of this registration form and payment. Contact: [email protected], Phone: (703) 856-7057, http://www.discoverlearningcenterva.com/