Legal Guardian First Name
Last Name
Relationship
Cell Phone
Work Phone
Email Address
Address Line 1
Address Line 2
City
State
ZIP
Guardian 2 Name
Guardian 2 Phone
Guardian 2 Email
Camper Info (Name / DOB / Age / Gender / Medical Conditions / Allergies / Current School / Fall School (if different) / Grade entering in the FALL)
Camper 2's Info (Name / DOB / Age / Gender / Medical Conditions / Allergies / Current School / Fall School (if different) / Grade entering in the FALL)
Camper 3's Info (Name / DOB / Age / Gender / Medical Conditions / Allergies / Current School / Fall School (if different) / Grade entering in the FALL)
Camper 4's Info (Name / DOB / Age / Gender / Medical Conditions / Allergies / Current School / Fall School (if different) / Grade entering in the FALL)
Pediatrician & Phone #:
Attendance / Tuition - NOTE: Contact us for special requirements and multiple sibling discounts.
Sessions 1 & 2
Session 1 only
Session 2 only
Weekly Enrollment
From whom or how did you hear about Jordan Glen?
Anything Else We Need To Know?
EMERGENCY TREATMENT RELEASE AND PERMISSION. Dates when release intended: JUNE / JULY 2025. To Whom It May Concern: As a parent or guardian, I do herewith authorize the treatment of the following minor(s) in the event that attending personnel deems it indicated to avoid disfigurement, physical impairment or undue discomfort if delayed. This includes allowing Jordan Glen (JG) staff to administer over-the-counter medications such as Ibuprofen, Tylenol and Benadryl unless expressly prohibited by parent below. It is understood that efforts will be made to reach me as soon as practicable. I also give JG permission to use my, or my minor child's, likeness, image, voice, and/or appearance as such may be embodied in any form of media, i.e. pictures, photos, video recordings, audiotapes, digital images, etc., taken by or made on behalf of JG. I agree that JG and its directors have complete ownership and copyright of such media and that I will not receive any compensation for the use of such media.
I hereby release JG and its agents and assigns from any and all claims which arise out of or are in any way connected to any actions as described in this paragraph. *
EMERGENCY TREATMENT RELEASE AND PERMISSION. Dates when release intended: JUNE / JULY 2025. To Whom It May Concern: As a parent or guardian, I do herewith authorize the treatment of the following minor(s) in the event that attending personnel deems it indicated to avoid disfigurement, physical impairment or undue discomfort if delayed. This includes allowing Jordan Glen (JG) staff to administer over-the-counter medications such as Ibuprofen, Tylenol and Benadryl unless expressly prohibited by parent below. It is understood that efforts will be made to reach me as soon as practicable. I also give JG permission to use my, or my minor child's, likeness, image, voice, and/or appearance as such may be embodied in any form of media, i.e. pictures, photos, video recordings, audiotapes, digital images, etc., taken by or made on behalf of JG. I agree that JG and its directors have complete ownership and copyright of such media and that I will not receive any compensation for the use of such media.
I hereby release JG and its agents and assigns from any and all claims which arise out of or are in any way connected to any actions as described in this paragraph. *
Date
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