Required Pre-Camp Health & Safety Intake Form

Thank you for registering for Summer Camp at La Tertulia! Your child's spot is officially secured. To ensure a safe, fun, and compliant camp environment, Washington State law requires us to keep current medical, emergency, and liability information on file. Please complete this mandatory health, safety, and media permissions form for each child attending at least one week prior to their first day of camp.

1. Camper Profile

Child's Name

Date of birth

Month

Day

Year

T shirt Size

2. Registered Camp Sessions

Select all sessions your child will attend

Mystery Camp June 29- July 2

Summer Session July 6-10

Summer Session July 13-17

3. Parent / Guardian Contact Info

Parent / Guardian Full Name

Phone

Email

Parent / Guardian Full Name

Phone

Email

4. Emergency Contacts & Authorized Pick-Up

* Note: Only individuals listed below will be allowed to pick up your child.

Emergency Contact Name *

Phone

Authorized Pick-Up #1 Name *

Relationship to Child

Phone

Authorized Pick-Up #2 Name *

Relationship to Child

Phone

5. Food Allergy & Medical Action Plan

Primary Care Physician

Health Insurance Provider & Plan ID number

Child has known allergies

No

Yes

B. Emergency Medication

Medication Storage Location During Camp Hours:

Instructions for Camp Staff regarding your child's medical needs while at camp.

6. Operations Policies & Late Pick-Up Fees

Pick-Up Policy: Summer Session Camp programming ends promptly at 3:30 PM. A grace period is extended until 3:45 PM. Starting at 3:46 PM, children will be admitted to our Extended Day program for a fee of $33.00 for the day. Late pick up from Extended Day is billed 15.00 for the first 15 minutes and $5.00 per minute onwards.

Mystery Camp June 29- July 2 ends promptly at 4:00PM and our grace period extends until 4:15. Starting at 4:16 PM, a late pick up fee of $15.00 for the first 15 min and $5.00 per minute onwards.

7. Camper Code of Conduct

Please review these community safety and language goals with your child prior to the first day of camp:

I will listen carefully to the camp staff and follow their directions.
I will be respectful with body (absolutely no rough play).
I will do my absolute best to practice listening to and speaking in Spanish while at camp.
I will be kind, use encouraging words, and show respect to all other campers.
I will stay safely with my assigned camp group at all times.

My child and I have read, understood, and agree to uphold this Code of Conduct and language goal.

8. Legal Waivers & Media Consent Choices

Liability Release & Medical Care: I give permission for my child to participate in all scheduled activities. I release, waive, and discharge La Tertulia Seattle LLC and its staff and volunteers from any liability for personal injury, sickness, or property damage. In a medical or allergic emergency, I authorize staff to follow standard emergency protocols, administer provided epinephrine/antihistamines, and call 911.

I accept full financial responsibility for all medical expenses incurred.

Promotional Media Consent *

Consent Granted: I permit photos/videos of my child for camp messages, La Tertulia website and our marketing.

Opt-Out Requested: I do NOT want my child photographed. (A colored wristband marker will be safely issued to your child at check-in to exclude them from media).

9. Authorization Electronic Sign-Off

By typing or signing your full legal name below, you certify that all information submitted on this form is accurate, and you explicitly agree to all terms, waivers, late fees, and allergy action protocols outlined above.

Signature

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