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SUMMER CAMP REGISTRATION FORM
Little Learner’s Speech and Language Summer Camps at The Chesney Center for Speech, Language &
Listening are targeted for children in grades pre-k through kindergarten and focus on grade-level expectations
as defined by the Louisiana Department of Education to promote communication skills necessary for academic
success.
CURRENT CONTACT INFORMATION
Child’s Name:
_____________
Age: ________________________
Grade entering in fall of 2013: ______________________________
Mother’s Name:
Date of Birth: _________________
Father’s Name:
___________
Address:
City: _____________ State: _____ Zip: ____________
Mother’s Cell Phone:
Father’s Cell Phone:
Email:
_____
_______________________________________________
Emergency Contact (other than parent): _______________________ Phone: __________________________
Please list any allergies or medical conditions: ____________________________________________________
PLEASE CIRCLE THE WEEK/WEEKS YOUR CHILD WILL BE ATTENDING
A one-time $50 non-refundable registration fee is required per child to be paid by April 30 ($75 by May 1).
Early Bird registration is $135 per session paid 4 weeks prior to session attending.
Sessions
Time
Theme
Early Bird
Discount
$50 (4/31)
One Time Registration Fee
Regular Session
Amount
$75
June 10, 12, 14
June 17, 19, 21
June 24, 26, 28
9 a.m. – 12 p.m.
9 a.m. – 12 p.m.
9 a.m. – 12 p.m.
“Going Camping”
“At the Beach”
“Who’s In the Jungle?”
$135 (5/13)*
$135 (5/20)
$135 (5/27)
$150
$150
$150
July 8, 10, 12
July 15, 17, 19
July 22, 24, 26
9 a.m. – 12 p.m.
9 a.m. – 12 p.m.
9 a.m. – 12 p.m.
“On the Farm”
“Bears, Bears, Bears!”
“All About Me”
$135 (6/10)
$135 (6/17)
$135 (6/24)
$150
$150
$150
Total Payment Enclosed:
$ ______________
*This indicates the deadline of the Early Bird discount for each session.
5422 Superior Drive Ste. B
Baton Rouge, LA 70816
Main Phone 225.302.5030 Fax 225.372.2604
www.thechesneycenter.com
PAYMENT INFORMATION
Method of Payment: _______ Check Enclosed
_______MasterCard
_______Visa
_______ AmEx
Name on Card: ___________________________________ Signature: _______________________________
Card Number: _________________________
Expiration: ________________ Security Code: ________
*All checks must be made payable to The Chesney Center for Speech, Language & Listening
PHOTOGRAPHY RELEASE
I grant permission to The Chesney Center for Speech, Language & Listening to photograph my child,
__________________________, who is participating in the Little Learner’s Speech and Language Summer
Camp. I also give permission to The Chesney Center for Speech, Language & Listening to use the photographs
for promotional purposes, including, but not limited to, The Chesney Center for Speech, Language & Listening
website, brochures, camp guide, facebook page and other marketing and communication materials.
Parent/Guardian Signature: __________________________________________
Date: ________________
MEDICAL EMERGENCY RELEASE
*This section must be completed by a parent/guardian for all session registrations.
In case of injury or illness, I wish to be contacted as soon as possible at the telephone number listed on the
previous page. If I cannot be reached, please contact the emergency number listed on the previous page. If I or
the emergency contact cannot be reached in the event of serious injury/illness, I grant permission to The
Chesney Center for Speech, Language & Listening to contact a physician and secure proper emergency
treatment, while efforts to locate the parents continue. In the event of serious illness/injury, and so that my
child may be sent to a local hospital via ambulance, I understand that I am responsible for all charges either
through health insurance or otherwise.
Pediatrician’s Name: _______________________________________________
Phone: ________________
Name of Facility: ___________________________________________________________________________
Parent/Guardian Signature: __________________________________________
5422 Superior Drive Ste. B
Baton Rouge, LA 70816
Main Phone 225.302.5030 Fax 225.372.2604
Date: _________________
www.thechesneycenter.com
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