Choices Leadership Academy 18106 Marsh Lane Dallas, Texas 75287 S U M M E R C A M P S U C C E S S

1. Choices Leadership Academy 18106 Marsh Lane Dallas, Texas 75287 SUMMERCAMP SUCCESS READING*WRITING* MATH*COMPUTER*DRAMA*SPORTS STUDY SKILLS * FIELD TRIPS*LEADERSHIP * ART * SPANISH JUNE 8 thru JULY 17 GRADES 3-6 972-662-0665 www.choicesleadership.org

2. Choices Leadership Academy Summer Camp Success *Sign Up For One Week Or All Six *New Academic & Enrichment Activities Each Week *Grades 3rd-6th *7:30a.m.- 6:00p.m. *CLASS TIME: 8:30am-3:30pm *Before Camp Care: 7:30am-8:30am *After Camp Care: 3:30pm-6:00pm *Bring A Sack Lunch & Snack *Tuition $100 Per Week SUMMER SESSIONS Session I June 8 - 12 Session II June 15 - 19 Session III June 22 - 26 Session IV June 29 - July 2 Session V July 6 - 10 Session VI July 13 - 17

3. CAMP SUCCESS T-SHIRT FOR EACH CAMPER!!! ALL BOOKS AND LEARNING TOOLS SUPPLIED BY CAMP SUCCESS FUN FRIDAY IN HOUSE FIELD TRIPS WITH SPECIAL GUESTS!!! WIN PRIZES FOR DOING CAMP HOMEWORK!!!! LEARN FROM GREAT TEACHERS!!! TWO CINEMARK MOVIE FRIDAYS!!! *Popcorn *Hot Dogs FUN!!! FUN!!! FUN!!! MAKE COOL FRIENDS BE A STAR!!! ENJOY SPORTS & FITNESS!!!

4. Registration Release Form MEDICAL INFORMATION Physician_____________________________________ Phone( )_______________________ Any health concerns or activity restrictions__________________________________________ Does student take prescription medication? Yes__ No___ If yes, what medication__________________________________________________________ Medications must be supplied by the parents and brought to camp in the original container and properly labeled with the name of the student, name of the medication, dosage amount and time the medication is to be administered. All medications must be taken to the Camp Office. MEDICAL RELEASE I hereby certify that my child is in good health and may participate in all activities. In case of an emergency, I give my permission for my child to be given emergency treatment at any hospital reasonably accessible. Parent/Guardian Signature_______________________________________________________ Relationship__________________________________________ Date____________________ WAIVER OF CLAIM & PHOTOGRAPHY RELEASE I hereby permit my child, herein after referred to as Participant to participate in the Choices Leadership Academy Summer Programs and related activities including field trips requiring transportation by bus or van, sponsored by Choices Leadership Incorporated. I hereby release Choices Leadership Academy and it’s staff members and other persons and entities associated from any and all liability and responsibility for accidents or injuries arising. I hereby permit Choices Leadership Academy Summer Programs to use in whole or in part, photographs, videos, written extraction, and voice recordings of the Participant for the purpose of illustrations and publications, including the Choices Leadership Academy website or newsletter. No Participant’s name will be published without parent permission. I have read and understood the foregoing Consent, Release and Waiver and I waive any and all claims, suits and causes of action related thereto. I further understand that except for my Consent, Release and Waiver in these respects the Participant will not be permitted to participate in the Choices Leadership Academy Summer Programs and related activities. Parent/Guardian Signature_______________________________________ Date___________ Registration Form DETACH AND COMPLETE FORM Mail, Deliver or Fax Registration Form and Tuition To: Choices Leadership Academy 18106 Marsh Lane Dallas, Texas 75287 972-662-0665 Fax 972-307-3440 Last Name__________________________First__________________________________ Grade___School____________________Age___Birthdate_________________________ Parent/Guardian___________________________________________________________ Address_____________________________City_________Zip_______________________ Phone( )______________________________Cell( )_____________________________ Work( )_______________________E-mail_____________________________________ Name of person to contact if parent cannot be reached: Name______________________________ Phone________________________________ NONREFUNDABLE REGISTRATION FEE $25 DUE FOR EACH CAMP *Fee Is Applied To Each Camp Tuition *Registration Deadline May 29 CAMP SESSIONGRADETUITION _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ *Confirmation of Payment Mailed After Registration Received* Total Tuition Fees_______________ Registration Fees_______________ ( Balance Due Week Before Each Camp ) Tuition Balance_________________ Make Payment To: Choices Leadership Academy ___ Check Drivers License Number ___________________________(Required for checks) ___MasterCard ___VISA Credit Card Number _____________________________Expiration Date______________ Authorized Signature for Credit Card:__________________________________________ Please Print Name On Card__________________________________________________