Summer Camp Detailed Registration Form

Little Launchpad is a fun-packed faith-based STEM (Science Technology Engineering and Math) program where we explore God’s love for your children and all His creation through hands-on experiments, exciting activities, immersive field trips, and acts of service.

This year, the dates for the program will be July 20th-31st, 2020. Virtual program hours are from 9am-12pm, with afternoon in-person activities and field trips.

The cost of the program for each participant is $80. Deposit to hold a spot is $25 and the registration fee is being determined by fundraising efforts and will be announced soon. Scholarships are available.

Please fill out the information below to register your child for Little Launchpad and hold a spot for this coming summer!

We will be partnering with UB Tech and the Brideport STEM Ecosystem to offer robot building for our 3-5th graders, Bridgeport Youth Lacrosse to offer outside in-person introduction to the sport of lacrosse.

COVD-19 Procedures

We will be taking at least 2 field trips. To maintain social distancing, we are asking parents to transport their children to, and attend field trips.

All activities with Bridgeport Youth Lacrosse will be outside and will require wearing masks. Equipment will be sanitized regularly.

Student Information

Student's Name

First Name Last Name

Birth Date

Month Day Year

Grade

Gender

Male Female

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Parent/Guardian Information

Name

First Name Last Name

Home Number

Area Code Phone Number

Cell Number

Area Code Phone Number

E-mail

Emergency Information

Emergency Contact's Name

First Name Last Name

Relationship

Phone Number

Area Code Phone Number

Alt. Phone Number

Area Code Phone Number

Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the student prescribed an inhaler? If yes, please explain any instructions.

The deposit for camp is $25 to hold a spot.

How will you pay for the deposit and registration fee?

NVIM.org/give Cash App $NVIMgive35 Cash in Check in person I would like to apply for a scholarship

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Little Launchpad (LL) at New Vision International Ministries (NVIM) during the selected camp. In exchange for the acceptance of said child’s candidacy by LL at NVIM, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless LL at NVIM, and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected program sessions.

In case of injury to said child, I hereby waive all claims against LL at NVIM including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named student. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to LL at NVIM and its affiliates including Directors, teachers, and volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Sign Here

By typing your name you acknowledge and approve of the information above

Little Launchpad Registration