ashkids

We'll handle the kid stuff.	Children's Program Registration Form - American Society of Hematology - December 8-11, 2012

If you prefer to download an Adobe Acrobat version of this form to mail or fax to us,
click here: Acrobat Version of Registration Form.

Where, When, For Whom

The children's program is for children ages 6 months through 12 years old and will be located at the Georgia World Congress Center in Atlanta, Georgia. Food and beverages will be provided. If your child has specific dietary requirements, you must provide your own meals.

Medication will NOT be administered by KiddieCorp. Be sure to fill out the following form COMPLETELY. To ensure a safe and fun-filled environment, any child who is ill will not be admitted to the children's program. If any children need special attention, please call KiddieCorp directly at (858) 455-1718. Any additional costs will be the responsibility of the parents. The cost for the children's program is $5.00 per hour, per child (2-hour minimum required per child per day).

The pre-registration deadline is November 7, 2012. This form must be completed in its entirety and payment received before registration is confirmed.

Cancellations must be made to KiddieCorp prior to November 7, 2012 for a full refund. Cancellations made after that date will be subject to a 50% cancellation fee. Once the program has begun, no refunds will be issued.

Parent Information:

Parent Name(s):

Home Phone:

Work Phone:

E-mail Address:

Full Mailing Address:

Check here if your child(ren) has/have any special needs under the Americans with Disabilities Act. We will contact you so that we may make appropriate arrangements to accommodate your child. Please provide details in the box below.

Check here if any of your children have health limitations or special needs. Please let us know so that we may ensure your child(ren)'s needs are met. Please provide details in the box below.

Child(ren)'s Names and Ages

1. Name: Age: At the time of the meeting.

2. Name: Age: At the time of the meeting.

3. Name: Age: At the time of the meeting.

4. Name: Age: At the time of the meeting.

5. Name: Age: At the time of the meeting.

Dates & Times

Saturday, December 8

6:30am-7:30pm

Drop-off Time: am pm Pick-up Time: am pm

Sunday, December 9

6:30am-8:00pm

Drop-off Time: am pm Pick-up Time: am pm

Monday, December 10

6:30am-8:00pm

Drop-off Time: am pm Pick-up Time: am pm

Tuesday, December 11

6:30am-1:00pm

Drop-off Time: am pm Pick-up Time: am pm

Please provide any additional details in the box below.

Payment in full is required to confirm your reservations. Although every effort will be made to accommodate late or on-site registrations, there is no guarantee that KiddieCorp can accept children unless they are pre-registered. When you arrive at the children's program we will have you complete a consent form.

Calculating Fees & Payment Options:

*$5.00 per hour, per child X # of children X # of hours =**

*Children must be registered for a minimum of two consecutive hours per child, per day.

KiddieCorp accepts checks and money orders (in U.S. dollars only), MasterCard, Visa and American Express.

If you are paying by credit card, please enter your card number and print a copy of this completed registration form for your records BEFORE you submit on-line. Confirmations will not be sent. If you prefer, you may fax the form to (858) 455-5841.

VISA MASTERCARD AMERICAN EXPRESS
Credit Card #: Expiration Date: Verification Code:

If you are paying by check, please print two copies of this completed registration form. Confirmations will not be sent. Keep one copy for your records and mail the other copy along with your check or money order to:

KiddieCorp/ASH
8961 Complex Drive
San Diego, CA 92123
(858) 455-1718