Middle School Summer Workshop

Middle School Summer Workshop

Registration Form
STUDENT INFORMATION
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*

MaleFemale
PARENT INFORMATION
Parent #1 Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Number*

Area CodePhone Number
Work Number

Area CodePhone Number
E-mail*
Parent #2 Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Number*

Area CodePhone Number
Work Number

Area CodePhone Number
E-mail*
If parents are legally separated or divorced, who is authorized to make decisions on behalf of the minor?
Emergency Contact Information
Emergency Contact Full Name*

First NameLast Name
Emergency Contact Relationship:*
Emergency Contact Number*

Area CodePhone Number
Allergies:
Is there anything we need to know for the SAFETY of your child or others while he or she is in our care?
Does your child have any condition that would prevent him/her from participating in any camp activities?
RECOMMENDATIONS/RESTRICTIONS WHILE AT CAMP
Allergies (food, drugs, etc.):
We are trained in proper usage and administration of Epi-pens. In the unlikely event we suspect your child is having a severe anaphalactic reaction, is there any known medical reason why your child should NOT be administered epinephine?
Opt-out for Epi-pen

YesNo
Bee Stings, Mosquitos:
Asthma or Hay Fever:
Serious Injuries/Illnesses:
Reason:
Child's Name:
a minor, do hereby authorize the directors of Social Foundations LLC for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by and is to be rendered under the general or special supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but it is given to provide authority and power on the part of aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician or surgeon in the exercise of his/her best judgment may deem advisable. This authorization shall remain effect until January 10, 2021 unless sooner revoked in writing and delivered to said agents.
Authorize:*

check here
Parent/Guardian Name:*

First NameLast Name
SESSION INFORMATION
Social Foundations Summer Workshops will be held at:
4530 Jasmine Ave Culver City CA 9023

Ages: Coed, entering 6th, 7th, or 8th grade

Dates and Time: Mondays, July 11, 18, 25, Aug 1, 8, 15
4:00-5:30pm

Cost: $900
INITIALS*
Refunds: Refunds will only be given if Social Foundations needs to cancel or postpone camp due to Covid-19 updates.
INITIALS*
I understand and agree to the policies of Social Foundations LLC, as described above.
Student's Full Name*

First NameLast Name
Parent Signature:*
Typed name is an e-signature
Date:*

MonthDayYear
PARENTAL/LEGAL GUARDIAN CONSENT AND RELEASE

PLEASE READ CAREFULLY

THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS

WAIVER / RELEASE / ASSUMPTION OF RISK
PRINT PARENT/LEGAL GUARDIAN’S NAME: :*
PARENT/LEGAL GUARDIAN’S SIGNATURE:*
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Middle School Summer Workshop$900.00
Payment Methods

Fastlane Checkout

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Contact Info

Payment Info
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STUDENT INFORMATION

PARENT INFORMATION

Emergency Contact Information

RECOMMENDATIONS/RESTRICTIONS WHILE AT CAMP

SESSION INFORMATION