SUMMER EXPERIENCE SERIES - Register Here
Your Name:
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First Name
Last Name
Date of Birth:
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Email Address:
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Email
Mobile Number:
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Secondary Number:
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Gender:
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Home Address with Zip Code:
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Which school do you currently attend?
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T-Shirt Size:
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Please Select
Small
Medium
Large
X-Large
2XL
3XL
Race:
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Please Select
Asian
Black or African American
Native American/Alaska Native
Native Hawaiian/Pacific Islander
White
Other Race or Biracial
Ethnicity:
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Please Select
Hispanic or Latino
NOT Hispanic or Latino
Race/Ethnicity:
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Language Spoken at Home:
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Which camp experiences are you registering for? (Check All That Apply)*
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Business and Entrepreneurship (June 24th – June 27th, 1:00 PM – 4:00 PM)
Early Childhood Education / Community and Human Services (July 8th – July 11th, 1:00 PM – 4:00 PM)
Esports / Media & Technology (July 15th – 18th, 1:00 PM – 4:00 PM)
Criminal Justice (July 22nd – July 26th, 1:00 PM – 4:00 PM)
PARENTAL CONSENT: My signature serves as my approval for my child to participate in the Summer Experience at Esperanza College. I understand that the camp will be held onsite at the college located at 4261 N 5th street, Philadelphia, PA 19140.
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Signature
Parent Information: Email Address
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Parent Information: Phone Number
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Parent Information: Home Address
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Photographic Release and Emergency/Medical Waiver for Adults
I hereby grant Esperanza College and parties designated by Esperanza College, including clients, licensees, purchasers, agencies and periodicals, the irrevocable rights to use my photographs and video/s for release and reproduction in any medium including, but not limited to print electronic (e.g. internet) for purposes of advertising, trade, display, exhibition or editorial use, Furthermore, I waive any and all rights to inspect or approve any finished or unfinished photographs, videotapes or other means of production referred to herein, so long as the use is of lawful purpose. [Parent Consent: I have read, understand and agree to the terms and conditions specified in the above statement and have provided my signature (writing my name below) as confirmation.]
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I hereby allow the reproduction and publication of my child’s photograph(s).
I do not allow the reproduction and publication of my child’s photograph(s).
I am at least 18 years of age and have read the statement and thoroughly understand the terms and conditions of this release. I hereby give my permission to Esperanza College of Eastern University and Nueva Esperanza, Inc. employees to secure proper medical care for myself as deemed necessary in the event I cannot be reached in an emergency. This permission extends from minor first-aid treatment to hospitalization if necessary.
Submit
Esperanza College of Eastern University
4261 N. 5th Street
Philadelphia, PA 19140
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