Launchpad Summer Camp Application

Student Information*

	Name	Grade
Child 1
Child 2
Child 3
Child 4
Child 5

Do any of the above children have allergies, asthma, medications, or special needs? If yes, please explain.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

T-Shirt Size

All participants will receive a Launchpad Summer Camp T-Shirt to wear on outings and field trips.

Parent/Guardian Name*

First NameLast Name

Relationship*

(Father, Mother, Guardian, etc.)

Phone Number*

Area CodePhone Number

Email*

example@example.com

Registration fee is required for each child. The participant will not be able to attend camp with unpaid fees.

Registration FeeEach participant is required to pay a registration fee of $30. The registration fee will cover a Launchpad Summer camp t-shirt and a reusable water bottle. Field trips will be a separate cost due the week of the outing.

$30.00 Quantity
Item subtotal:$0.00

Total

$0.00

I acknowledge that my child will be participating in a summer camp experience where behavioral standards are expected to be followed.
I understand that my child can be suspended and/or removed from Launchpad Learning Center for extreme misbehavior such as; fighting, sexual assault, or any other behavior deemed intolerable by Launchpad staff for the safety of other students.
I confirm that I will notify the Launchpad staff if my child has any special needs.
I confirm that we (parents/guardians) will be responsible for providing my child(ren) with suitable clothing and shoes in order to be active and safe during camp.
Payments for sessions will be made in advance for the week for all children attending camp. I understand my student will not be permitted without payment.

Covid/Liability Waiver

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I further acknowledge that ICT Launchpad Inc has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that ICT Launchpad Inc can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, and other clients and their families.
I voluntarily seek services provided by ICT Launchpad Inc and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.
I attest that:
* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
* I have not traveled internationally within the last 14 days.
* I have not traveled to a highly impacted area within the United States of America in the last 14 days.
* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
I hereby release and agree to hold ICT Launchpad Inc harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the Launchpad, or that may otherwise arise in any way in connection with any services received from ICT Launchpad Inc. I understand that this release discharges ICT Launchpad Inc from any liability or claim that I, my heirs, or any personal representatives may have against the Launchpad with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from ICT Launchpad Inc. This liability waiver and release extends to the Launchpad together with all owners, partners, and employees.

Parent Signature*

Date Signed*

Date

Payment Methods

Debit or Credit Card

First Name

Last Name

Credit Card Number

Security Code

Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Launchpad Summer Camp Application

Parent/Guardian Details

Acknowledgment

3926 E 13th St. Wichita, KS 67208