Summer Programs

Hospital / Clinic Preference*
Medical Physician's Name*
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Physician's Phone Number*
Medical Insurance Company
Insurance Details
Allergies / Special Health Considerations*
How did you learn about PeaceNJoy Academy?*
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Extended Comments
Special remarks about myself, my child, my needs, and any other concerns.
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Agreement*

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of a medical emergency.

I release PeaceNJoy Academy and its Management and Staff from liability in case of accident during activities related to PeaceNJoy Academy, as long as normal safety procedures have been taken.

I accept that tuition is based on the school year and there is no credit for any absence. There are no refunds, tuition adjustment, or make up days when my child is absent due to weather, holidays, illness, or family vacation. Full payment is required to maintain a place for my child on the school register.
Digital Signature of Parent*

Date of Application Submission *

Primary Email Address*

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