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00 The Hobbit Hole 3805 Jodeco Road McDonough, Ga 30253 Tel: (404) 983-228217145076201 GAMER’S DAY CAMP REGISTRATION FORM0 GAMER’S DAY CAMP REGISTRATION FORM (PLEASE PRINT OUT CLEARLY. IF THE INFORMATION IS ALREADY FILLED IN, PLEASE TURN IN TO THE HOBBIT HOLE VIA EMAIL (THEHOBBITHOLEATJODECO@) OR IN-STORE.)Name of Camper: ___________________________________________________________________Mailing Address: __________________________________________________________________City: ______________________________ State: ____________ Zip Code:__________________________Home Phone: _______________________________ Day Phone: ___________________________________Birth Date: _________________________________ Age: _________________________________________Emergency Contact: _______________________________________________________________________Phone: ___________________________ Relationship to Camper: ___________________________________Parent/Guardian Name: ____________________________________________________________________Home Phone: ________________________ Day Phone: ___________________________________________Allergies/ Medical Needs: ___________________________________________________________________PARENTS PLEASE READ THE FOLLOWING VERY CAREFULLY: Medical Release My signature below indicates that I understand that my child is being enrolled in a half day summer camp program to be presented by The Hobbit Hole from 8 am to 4 pm Monday-Friday. As parent/ guardian, I understand that should my child need medical attention in an emergency, every effort will be made to contact me. However, in the event that I cannot be reached, I hereby grant permission for Terry Bishop or another Hobbit Hole designee to order emergency medical treatment, x-rays, routine tests, release of any personal contact information, and to provide/ arrange for transportation for my child to a medical care facility. In my absence, I hereby give permission for emergency personnel or a physician to provide medical treatment, hospitalization, injection, anesthesia, or surgery, should the situation call for any of these things. I understand that I will be financially responsible for all costs incurred by any medical situation. It is recommended by The Hobbit Hole that children provide medical insurance information above, prior to submitting this form. In the event of an accident, I hereby consent to hold harmless all Hobbit Hole designees. I hereby waive my right to claims against any Hobbit Hole designees. I understand that the summer camp times are 8 am to 4 pm, Mondays through Fridays. I will ensure that my child arrives on time and is picked up promptly at 4: 30 pm. I also understand that my child is expected to behave appropriately during all camp days, and may be asked to leave camp (without a refund) if he/ she is unable to conduct himself/ herself appropriately during the activities. I have read and understand all of the above information: __________________________________________ ___________________________Parent/Guardian Signature DatePAYMENT INFORMATION-914400453Registration for June 20 -24, 2016Please charge my credit/debit card today for $ 150.00I am paying in full by check in the amount of $ 150.00I am paying in cash in the amount of $ 150.00Type of PaymentVisaMaster CardAmerican ExpressDiscover CardCheck or Money OrderCash Card #: _____________________ Expiration: _________ Name on Card: ______________ CCV Code: ________Signature: ____________________________________________00Registration for June 20 -24, 2016Please charge my credit/debit card today for $ 150.00I am paying in full by check in the amount of $ 150.00I am paying in cash in the amount of $ 150.00Type of PaymentVisaMaster CardAmerican ExpressDiscover CardCheck or Money OrderCash Card #: _____________________ Expiration: _________ Name on Card: ______________ CCV Code: ________Signature: ____________________________________________All above information will be held responsible of the Hobbit Hole. Documentation of card information will be destroyed after the card of choice is charged. All information pertaining to a child will be properly filed to meet the standards of the child and the Hobbit Hole. ................
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