Russian Language Learning Center

PHILIPOK, LLC

P.O. Box 241944 Milwaukee, WI – 53224

Phone # (414) 732-6093 or (414) 405-2094

E-mail: vcoach@wi.rr.com

Summer Camp Philipok-2007 Application

Application and registration fee due date is May 18, 2007.

The remaining balance should be paid in full by June 8^th, 2007.

Please, make your check payable to Philipok, LLC.

$50.00 refundable registration fee is required at the time of application

Camp fee covers all the expenses including:

Bus transportation; breakfast and afternoon snacks; admission fees.

20% discount for a second child from the same family.

Camp Sessions Information: (Please, indicate your choice by checking as many boxes below as applicable)

Two-Week Sessions:

❐ Session 1 Age 5 – 12 June 18 – June 29 $365

❐ Session 2 Age 5 – 12 July 02 – July 13 $328.50

❐ Session 3 Age 5 – 12 July 16 – July 27 $365

❐ Session 4 Age 5 – 12 July 30 – August 10 $365

Part -Time Attendance ( please, indicate the days of your choice M-F):

Two days a week - $150.00 _________________________________________

Three days a week- $240.00 _________________________________________

Four days a week - $320.00 _________________________________________

I. Camper Information:

Camper’s F/L Name: __________________________ Date of Birth: ______ Age: ___

❐ Male ❐ Female

Home Phone: ___________________________________________________________

Street: __________________________ City: ___________ State: __ Zip Code: _____

II. Parents Information:

Mother: Last Name: __________________ First Name: ___________________

Home Phone: _____________ Business Phone: __________ Cell: ____________

Father: Last Name: ___________________ First Name:____________________

Home Phone: ____________ Business Phone: ____________ Cell: ____________

III. Emergency Contact: (If parents can not be reached, this person will be responsible for making decisions on their behalf.)

Emergency Contact Phone: ________________________

Emergency Contact’s Relationship to Camper___________________________

HEALTH INFORMATION

1. Does you child have any chronic health issues? _____yes _____no

. If answered YES please, provide detailed information about the condition:

_______________________________________________________________________________________________________________________________________________

2. Does your child take medication? _____yes ______no

3. Will this health condition prevent your child from participating in all scheduled activities during camp hours, such as swimming, hiking, running, being outdoors, etc?

_____yes _____no

4. Was your child exposed to any infectious disease within past three weeks?

_____yes ____no

If answered YES please, provide detailed information: ______________________________________________________________________________________________________________________________________

5. Does your child have any special needs ______yes _____no

________________________________________________________________________

I, ____________________ give my permission for _________________ (child’s name) to participate in all camp activities.

Parent’s Signature: ____________________________________________________

MEDICAL CARE/INSURANCE INFORMATION

Please, provide name, phone # and address of your child’s pediatrician:

________________________________________________________________________________________________________________________________________________

Name of insurance company                                                                    ______________

ID # (child’s) _________________

Affiliated hospitals _______________________________________________________

I understand that the staff of the Philipok, LLC will make every reasonable effort to utilize health insurance information provided by me to locate appropriate treatment facility in case of emergency. I understand that the preference will be given to the nearest hospital to reassure the safety of my child.

I HEREBY GIVE MY PERMISSION FOR________________________TO BE TREATED BY ANY PHYSICIAN IN THE NEAREST HOSPITAL IN CASE OF EMERGENCY.

_________________________________________________

(Signature of parent or guardian)

CANCELLATION/REFUND POLICY:

In order to receive a partial refund a written notice of cancellation must be received at least 2 weeks prior to the opening date of the session for which the camper is registered. A $25.00 fee will be assessed for all cancellations.

DIRECTIONS:

The camp is located at 2315 West Good Hope Rd.

Taking I 43

Exit on West Good Hope. Take Good Hope West for about 1 mile. Pass traffic lights Turn left to Good Hope Elementary School. The school is located on the South side of Good Hope Rd., just half a bock west of the Green Bay/Good Hope intersection.

Taking I 45

Exit on Good Hope Rd. going east for about 4 miles. Turn right to Good Hope Elementary School. The school is located on the South side of Good Hope Rd., just half a block East of Range Lane Rd.

Check List for Camp

What to Bring
1. Lunch, preferably in metal lunch box
2. Bathing suit.  Pony tail holder for long hair

3. Towel, soap

4. Sunscreen cream
5. Sweater or sweatshirt, additional pair of shoes and t-shirt

WHAT NOT TO BRING: (These items will be confiscated)

alcohol, drugs, tobacco, knives, lighters/matches, ideas/supplies for practical jokes

What to Wear:

1.Shorts or jeans.
2. Shirt or blouse.
3. Sneakers, sandals.

4. Hat

Please!! Be sure that everything brought or worn to camp is clearly marked with your name.  It makes it so much easier for your counselor to locate any misplaced items!