1. science
2. medicine
3. pediatrics

Child’s Name: _________________________________
Male ____
Address: _______________________________________
City: __________________
Best Phone: ______________________
Female ___
DOB: ________
Zip: _______
Current School: _____________________ Grade: ______
Diagnosis: __________________________________________
T-Shirt size: ______________________
Parent/Guardian
Parent/Guardian #1 Name: ___________________________________
Cell Phone: ______________
Email Address: ___________________________________________________________
Parent/Guardian #2 Name: ___________________________________
Cell Phone: ______________
Email Address: ___________________________________________________________
Other persons authorized by parent(s)/guardian(s) to pick up child without prior notification:
Name
Phone
(
)
(
)
Relationship
(
)
If PPCC is unable to reach either parent/guardian or emergency contacts, I give my permission to Progressive
Pediatric to consult my child’s physician, seek emergency medical treatment and/or emergency
transportation services if necessary. By signing below, I also agree to pay any medical expenses incurred for
treatment and/or emergency transportation.
Physician’s Name: ________________________________________ Phone number: __________________________
Physician’s Address: ________________________________________________________________________________
________________________________________________________________ ___________________________________
Signature of Parent/Guardian
Date
General Information:

Does your child have any special accommodation needs due to a disability? Please be detailed.

Does your child have any allergies that we should know about? Please be detailed.
Summer Escape 2015 Program Details
~ Camp runs June 8 - August 7 and is for children ages 2 through 12.
~ Camp activities include: developmental play, fine and gross motor activities, arts & crafts,
sensory & gym room play, activities to enhance daily living and social skills, music therapy
groups, outside play, circle time, academic skill reinforcement, and much more!
~ Camp rates and options:
Full Day Options (8:00am – 5:00pm,
Session A (4 weeks) June 8th – July 2nd
$920.00
Session B (5 weeks) July 6th – August 7th $1,150.00
9 Weeks
June 8th – August 7th $2,070.00
Monday – Friday)
Half Day Options (8:00am – 12:00pm OR 1:00
Session A (4 weeks) June 8th – July 2nd
$660.00
th
th
Session B (5 weeks) July 6 – August 7
$825.00
9 Weeks
June 8th – August 7th $1,485.00
- 5:00pm, Monday – Friday)
$870.00 if paid in full by 5/22/15
$1,090.00 if paid in full by 6/19/15
$1,860.00 if paid in full by 5/22/15
$625.00 if paid in full by 5/22/15
$780.00 if paid in full by 6/19/15
$1,335.00 if paid in full by 5/22/15
~ A $50.00 supply fee is due as part of your deposit. Make sure to list your child’s t-shirt size on
the first page of this packet. Each camper will receive an exclusive 2015 Summer Escape t-shirt.
If parents would like to order a shirt, please make note on your registration form. The cost will be added to your invoice.
~ Early drop-off at 7:30am and late pick-up at 5:30pm is available for an additional fee of
$10/week for each option.
~ We cannot guarantee a spot for your child until we receive a COMPLETED registration
form accompanied by the first week’s payment and $50.00 supply fee.
~ Once registration is complete, a camp packet will be emailed to you.
Multiple Children Discount: 10% discount for additional full-time and/or part-time children attending on a weekly basis.
This discount is applied to the lower weekly tuition.
Florida Administrative Code Requirements:
 Section 65C-22.006(3)(c)1 requires that parents receive a copy of the Child Care Facility Brochure,
“Know Your Child Care Facility”
 Section 65C-22.006(3)(c)2 requires that parents are notified in writing of the disciplinary practices
used by the child care facility
o Discipline Policy: At PPCC we demonstrate behavior modification strategies to help each child
learn how to regulate their own actions. We use praise and positive reinforcement to encourage
on-task behaviors. The staff is trained in behavioral techniques to facilitate the appropriate
redirection and/or level of communication needed for the specific developmental level of each
child. Discipline that is severe, humiliating, frightening, or associated with food, rest, or
toileting is prohibited. Spanking or any other form of physical punishment is not tolerated. A
child who is exhibiting aggressive behaviors will be encouraged to use strategies offered or
moved to a safe place until calm.
 Section 65C-22.006(3)(c)3 requires that parents receive information detailing the causes, symptoms,
and transmission of the influenza virus.
My signature certifies that I have received the above items.
________________________________________________________________ ___________________________________
Signature of Parent/Guardian
________________________________________________________________
Child’s Name
Date
2015 Summer Escape Session Selection
Select each session by marking in the corresponding box. If you are in need of early dropoff or late pick-up, please ensure to fill in the appropriate box. Total your fees under
Subtotal. This number does not include the $50.00 supply fee. If you will be paying in full
by the deadline, you will receive the corresponding discount.
 Session A – June 8th – July 2nd, 2015 (4 weeks)
Half Day
$660.00
8am-12pm
1-5pm
Full Day
$920.00
Early Drop-Off
$40.00
Late Pick-Up
$40.00
8am-5pm
7:30am
5:30pm
Subtotal
5% Discount
if paid in full
by 5/22/15
Subtotal
5% Discount
if paid in full
by 6/19/15
Subtotal
10% Discount
if paid in full
by 5/22/15
Mark
Selection
 Session B – July 6th – August 7th, 2015 (5 weeks)
Half Day
$825.00
8am-12pm
1-5pm
Full Day
$1150.00
Early Drop-Off
$50.00
Late Pick-Up
$50.00
8am-5pm
7:30am
5:30pm
Mark
Selection
 Entire 9 Weeks – June 8th – August 7th, 2015 (9 weeks)
Half Day
$1485.00
8am-12pm
Mark
Selection
1-5pm
Full Day
$2070.00
Early Drop-Off
$90.00
Late Pick-Up
$90.00
8am-5pm
7:30am
5:30pm
Summer Escape 2015 Payment Agreement
All sections of this form MUST be completed in full. We will not process an incomplete
payment agreement.
Child’s Name: _________________________________________________ DOB: ______________
In lieu of other funding sources and/or sponsorship opportunities (APD, Easter Seals,
etc.), I agree to pay Progressive Pediatric Child Care a total of $_________________ for:
Session A / Session B / 9 Weeks of Summer Escape.
(circle one)
To reserve a slot for my child, I have made the minimum payment of:
 $280.00 (Full Day Camp: $230.00 + $50.00 supply fee)
 $215.00 (Half Day Camp: $165.00 + $50.00 supply fee)
I will pay the remainder of my child’s Summer Escape balance:
 In Full by:
o May 22nd for Session A (5% discount applicable)
o June 19th for Session B (5% discount applicable)
o May 22nd for 9 Weeks (10% discount applicable)
 Weekly, by the Thursday prior to each week.
I understand that if a payment has not been made, my child will not be allowed to attend
camp. My account must be up-to-date prior to my child’s return to Summer Escape. In the
event that my payments get behind, I agree that I am responsible to pay the entire amount for
the session(s) I have enrolled. I will pay all weeks in the session whether or not my child
attends.
_________________________________________________
Signature of Parent/Guardian
______________________________
Date
_________________________________________________
Printed Name of Parent/Guardian
______________________________
Phone number
RELEASE OF LIABILITY & PARENT PERMISSION
In consideration for my child participating with Progressive Pediatric events and
activities, I, _____________________________________, shall indemnify, hold free and harmless,
assume liability for, and defend Progressive Pediatric, its officers and employees thereof
from any and all liability, claims or demands for personal injury, sickness or death, as well
as property damage and expenses, of any nature whatsoever which may be incurred by the
undersigned and the child-participant that occur while said child is participating in the
above described activity.
Furthermore, I, ________________________________, shall indemnify, hold free and
harmless, assume liability for, and defend Progressive Pediatric, its officers and employees
thereof any and all costs and expense including but not limited to, attorney’s fees,
reasonable investigative and discovery costs, court costs, and all other sums which
Progressive Pediatric, its officers and employees may become legally obligated to pay on
account of any, all and every demand for claim or assertion of liability, or any claim or
action founded thereon, arising or alleged to have arisen out of an intentional act or
omission of Progressive Pediatric’s, use of real or personal property belonging to Progressive
Pediatric, its officers and employees or by any intentional action or omission by Progressive
Pediatric, its members, agents, employees, officers or directors, for which Progressive
Pediatric, may be held legally liable.
In addition: (Check each box to acknowledge you have read and understand)






I have read the program information and give my child permission to attend and
participate in all phases of activities. I understand and agree that he/she is to
cooperate with all program regulations.
I give permission for my child to be treated in case of illness or emergency, and
understand I will be notified in an emergency situation.
I understand that if camp fees are not paid on time, my child will be unable to attend
camp until outstanding charges and current weekly payment has been made.
I understand that in case of cancellation, my camp fee is non-refundable. I will notify
Progressive Pediatric if my child is unable to attend his/her session as soon as I
become aware of circumstances.
I acknowledge that my account will be billed $1.00 per minute for picking up my child
late.
I agree that any pictures taken of my child may be used to promote Progressive
Pediatric.
Child’s Name: ___________________________________
Date of Birth: ________________________
Parent/Guardian Printed Name: _____________________________________
Date: _____________
Parent/Guardian Signature: _______________________________________________________________
1725 Hermitage Blvd * Tallahassee, FL 32308
Phone: (850)325-6301 Fax: (850)325-6302
Beth@progressivepediatric.org
www.progressivepediatric.org