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3. Please submit the completed form to the School Office.

INTERNATIONAL ENGLISH CAMP
SUMMER 2024
(PLEASE TYPE OR PRINT IN BLACK OR BLUE INK.)

Choose all that apply:

Enrolled at HCA for SY 2024-25: Yes□ Session 1: Immersion Program* (1 -12 )st□ No □ Next Grade:□ Session 2: Adventure Program** (1 -12 )stth$200 a week per student

th$350 a week per student□ 6/03-6/07 □ 6/10-6/14□ 6/17-6/21 □ 6/24-6/28□ 7/15-7/19*Late Stay (3:30-5:00 p.m.) is $15 per day (due on Fridays).

□ 7/22-7/26**No Late Stay for Session 2Student Information:
Last Name:First Name:

Birthdate:Age(in USA):

English Name:

Home Phone:Male:□ Female: □Mailing Address:
Father’s/Guardian’s Last Name:
Cell Phone:First Name:Work Phone:

Email:

Mother’s/Guardian’s Last Name:
Cell Phone:First Name:Work Phone:

Email:

Emergency Contact:

Mr.

□ Mrs. □ Miss □Last Name:

Home Phone:First Name:
Cell Phone:Work Phone: _______________________

Medical Information:□) OR Last TB X-Ray Date:(>4/1/24? □) w/ TB Form (if skin test positive) □Does your child have any drug allergy? Yes □ No □ If yes, please explain: _________________________________________
Does your child have any food allergy? Yes □ No □ If yes, please explain: __________________________________________
Does your child have any serious illness? Yes □ No □ If yes, please explain: ______________________________________
Does your child have any convulsions? Yes □ No □Does your child have any heart problems? Yes □ No □Does your child have any physical handicap? Yes □ No □ If yes, please explain: ___________________________________
Does your child take medicine on a regular basis? Yes □ No □ If yes, please explain: ________________________________
Does your child have any restrictions on physical activity? Yes □ No □ If yes, please explain: _________________________
Do you give permission for your child to receive Tylenol or any over-the counter medication if the need arises? Yes □ No □Last PPD Date:(>1/1/24?

By signing below, I agree to pay the applicable fees and submit the required documents with this application. I understand that the fees arenon-refundable. I also understand that I am responsible for other additional costs (food from the cafeteria, extended care, etc.) incurred
while my child is attending any summer programs of Harvest Christian Academy. I hereby give my child permission to attend
field trip activities upon notification. I hereby release HCA and its agents from liability for any injuries resulting from my child’sattendance. I grant permission to use photos from activities in their promotions.
I understand my child must be able tofollow all teacher instructions and participate in class. Behavior issues that cause safety issues may result in suspension. Allbehavior concerns must be directed to the International Director. As a parent, I agree to support the Administration of Harvest
Christian Academy; however, should I feel I can no longer support the Administration, I will promptly withdraw my child. To myknowledge, all information is complete and correct.
DATE

PRINT NAME

PARENT’S/GUARDIAN’S SIGNATUREFOR OFFICE USE ONLY:

Date:
Excel ĿTime:
FACTS Ŀ

P.O. Box 23189, Barrigada, Guam 96921 │ (671) 477-6341 │ hcaguam.org