Camper's Name
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First Name
Last Name
Camper's Date of Birth
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MM
DD
YYYY
Camper's Age
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Camper's School
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Parent's or Guardian's Name
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First Name
Last Name
Primary Email
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Home Phone
(###)
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Cell Phone
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(###)
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Primary Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Which weeks are you registering for?
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Select all weeks you will be attending. Any changes that need to be made can be emailed to info@southlaketutoringacademy.com with the subject line "Summer 2025 Week Change".
Three Day Packs
If you are purchasing any weeks of camp for three days only, please specify which weeks and which three days. Please be specific so we can prepare for your child's attendance.
I give my consent for my child to be transported and supervised by Southlake Tutoring Academy employees:
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Click all that apply.
I give consent for my child to participate in field trips.
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Yes
No
I give consent for my child to participate in the following water activities:
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Anything else we should know about your child?
List any special needs that your child may have, such as environmental allergies, food intolerances, existing illness, previous serious illness, injuries and hospitalizations during the past 12 past months, any medication prescribed for long term continuous use, and any other information which caregivers should be aware.
Emergency Contact #1
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First Name
Last Name
Emergency Contact #1 Phone Number
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(###)
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Emergency Contact #1 Relation
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Emergency Contact #2
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First Name
Last Name
Emergency Contact #2 Phone Number
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(###)
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Emergency Contact #2 Relation
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Insurance Provider
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Insurance Group #
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Insurance ID
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Urgent & Medical Care
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In the event that your child needs urgent care, STA will take your child to Cook Children's. In the event that your child needs emergency care, your child will be taken to Baylor Scott & White Medical Center.
If you are not attending the entire week of camp, which days will you be attending?
If none, leave blank.
Anything else you would like us to know?
If none, leave blank.
Southlake Tutoring Academy Consent
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Southlake Tutoring Academy (STA) Camp Waiver & Consent Form
Parental Consent & Acknowledgment of Participation:
On behalf of my minor child (student named on this application), I hereby give permission for my child to participate in the Southlake Tutoring Academy (STA) Camps. Activities may include, but are not limited to: games, experiments, exercise, aquatic activities, and outdoor activities. I acknowledge that my child’s participation in these activities is wholly voluntary.
Acknowledgment of Risk:
I hereby warrant that both my child and I are familiar with the risks associated with participation in STA Camps and agree to accept any and all inherent risks.
Hold Harmless Agreement:
I hereby release, absolve, indemnify, and hold harmless STA, its officers, directors, employees, contracted employees, independent contractors, instructors, agents, organizers, and volunteers from any and all liability for damage, injury, or expense of any kind arising out of or connected with my child’s participation in STA Camps.
Commitment to Being Reachable:
I commit to ensuring that either I or an emergency contact is reachable at all times during camp hours (9 AM – 4 PM) to answer a phone call from STA and its staff. I have provided a phone number where I or my designated emergency contact can be reached during camp hours. I also commit to being available or making arrangements for my child to be picked up for any reason and at any time.
Pick-Ups:
I commit to picking up my child or delegating that responsibility to an authorized adult. I will provide STA with written authorization for any adult permitted to pick up my child. I agree to pick up my child by 4:00 PM each day, or by 6:00 PM if I have paid for extended care. If I fail to do so, I understand that I will be billed $5 per minute past the designated pick-up time. I agree to pay any late pick-up fees; otherwise, my child's account will be placed on hold, and STA will not be able to accommodate my child in future programs until all outstanding fees are paid in full.
Discipline Policy and Dismissal Statement:
STA is committed to fostering a positive and respectful environment for all campers. Our staff is trained and authorized to guide students toward appropriate behavior and provide necessary, safe corrections to ensure a productive and secure camp experience. In the event of a significant violation of camp rules, STA reserves the right to implement appropriate disciplinary actions, which may include warnings, behavior correction strategies, or, in more serious cases, dismissal from camp.
If a child is dismissed from camp due to a violation of camp rules, no refunds will be issued for any unused portion of the camp. By signing this waiver, I acknowledge and understand that STA has the authority to take necessary actions to maintain a safe and respectful camp environment.
Child Will Abide By Rules and Regulations:
I have instructed my child to cooperate and comply with all reasonable directions and instructions received from camp staff. I understand that any violation of camp rules will result in consequences, and ultimately dismissal from camp. I understand that if my child is dismissed from the camp, I will not receive a refund for any unused portion of the pre-paid camp fee.
Consent to Administer Non-Emergency First Aid:
I understand and acknowledge that minor injuries or health issues may arise that require basic first aid. Therefore, I authorize STA and its staff to administer necessary non-emergency first aid, which may include but is not limited to: cleaning, applying antibiotic ointment to, and bandaging cuts or abrasions; removing ticks and splinters; and applying an ice pack to bites, stings, or injuries. The following substances may be used in the administration of non-emergency first aid: water, ice packs, ACE bandages, antibacterial soap, alcohol swabs, antibiotic ointment, and bandages. No oral medication will be administered unless explicitly authorized and directed by the child’s parent/guardian. If I do not consent to the administration of non-emergency First Aid or the use of any listed substances, I will provide written notification to STA no later than seven business days before the camp session begins.
Consent to Administer Emergency First Aid:
In the unlikely event of a life- or limb-threatening emergency, I give consent to STA and its staff to administer emergency first aid as a first response until more advanced medical care is available. I understand that STA and its staff will use their best judgment, act in good faith, and will treat my child with the intention of not causing further harm.
Consent to Arrange Emergency Treatment:
I understand and acknowledge that on rare occasions an emergency may develop that necessitates medical or dental care, hospitalization, or surgery for my child. Therefore, in the event of a serious injury or illness, I authorize STA and its staff to arrange necessary emergency treatment, including the administration of anesthetics and surgery. I also understand that a parent/guardian will be contacted at the earliest possible moment in the event of such an emergency.
Medical, Dental, Health, and Insurance Responsibilities:
I understand and acknowledge that STA cannot assume responsibility for determining the medical, dental, or health condition of my child. I confirm that I have consulted with a medical doctor and/or dentist, as necessary, regarding my child’s individual medical or dental needs and find my child physically and mentally fit to participate in STA Camps. If my child requires medical, dental, or hospital services during camp, I acknowledge that STA does not assume legal responsibility for payment of such costs. I assume full responsibility for these expenses and confirm that my child has the necessary insurance coverage to meet any and all medical needs while attending STA Camps.
Cancellation and Refund Policy:
Cancellation and refund requests must be submitted at least two weeks before the enrolled camps in order to receive a refund. You may cancel or switch to another week of camp, provided the request is made within the specified time frame. If a cancellation request is made less than two weeks before the scheduled camp, no refunds or transfers will be provided. Emergency situations will be processed case by case.
Photographic and Video Consent:
I consent to STA using photographs or videos of my child for promotional or educational purposes, including but not limited to brochures, websites, and social media, unless otherwise indicated in writing. If I do not wish for STA to use photographs or videos of my child, I will provide written notice to STA prior to the camp start date.
Child Abuse Reporting:
I understand that STA staff is required by law to report any suspected child abuse or neglect to the appropriate authorities, as required by the Texas Family Code.
Immunization Confirmation:
I affirm that my child’s immunizations are up-to-date as required by the Texas Department of State Health Services (DSHS) and acknowledge that STA may request documentation of such immunizations if necessary.
Compliance with Texas Child Care Licensing:
I acknowledge that STA operates in accordance with Texas Child Care Licensing regulations and ensures that staff members have passed the required background checks.
I Agree.
How did you find out about us?
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We want to make sure you receive any referral points that you may be eligible for! Please tell us how you heard about our Summer Camps!
