Afterschool Adventures Camp Registration 2023-2024 School Year Santa Cruz Learning Center

After School Adventures Camp Registration for the 2023-2024 School Year

Santa Cruz Learning Center
Participant Name (Student):

First NameLast Name
DOB of Student:

MonthDayYear
Date
Age of Student as of August 2023
Grade level Fall 2023
School (enter homeschool, if the student is not registered to a school)
What time does your child need to be picked up from school?
Which days do you wish for your child to attend After School Adventures Camp?

MondaysTuesdaysThursdays
What is your child's classroom number?
What is/are the name(s) of your child's teacher(s)?
Please describe the designated pick-up plan for your child. For instance, please meet them at their class room #4 or, my child will meet you at the school entrance, or at the top of the stairs on Prospect Heights, etc.
We will be transporting your child via minivan or SUV. We have boosters available for all our students. Will your child require a booster seat?
Information for Parent or Guardian 1
Parent or Guardian 1 Full Name:

First NameLast Name
Does the student live full time with parent or guardian 1? If no, please describe when the child stays with parent or guardian 1.
Parent/Guardian 1 Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship(s) of parent or guardian 1 to the student (mother, father, etc.)
Cell phone number of parent/guardian 1

Area CodePhone Number
Work phone of parent/guardian 1

Area CodePhone Number
Email for parent/guardian 1
example@example.com
Information for Parent or Guardian 2

Leave blank if only Parent or Guardian 1 is the only Parent or Guardian
Parent or Guardian 2 Full Name:

First NameLast Name
Does the child live full time with parent or guardian 2? If no, please describe when the child stays with parent or guardian 2.
Parent or Guardian 2 address Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship(s) of parent or guardian 2 to the student (mother, father, etc.)
Cell phone of parent/guardian 2

Area CodePhone Number
Work phone of parent/guardian 2

Area CodePhone Number
Email for parent/guardian 2
example@example.com

Participant Information

Tell us a little about the student
What types of activities does your child most enjoy doing?
Has your child ever been placed on a behavioral plan at school? If so, please give us some information about this.

RELEASE SECTION
Photo/video release: Santa Cruz Learning Center may use the above-listed participant's photo for promotional purposes. Does Santa Cruz Learning Center have permission to use photos or videos of your child?

YesNo
The parent or guardian signing on behalf of Member shall be responsible for payment of amounts owed to Santa Cruz Learning Center under this Agreement.*

Clear
In case of illness or accident, Santa Cruz Learning Center, is authorized to secure emergency medical treatment at my expense.*

Clear
The Santa Cruz Learning Center reserves the right to dismiss any participant who does not show respect for the facility, including but not limited to property, equipment, policies, other members, volunteers, and staff. Participants who are dismissed will not be given a refund of fees paid.*

Clear
The Santa Cruz Learning Center and its employees, contractors and volunteers assume no responsibility for personal property. By signing this enrollment form, I (we) herby waive any and all claims against Santa Cruz Learning Center and its employees, independent contractors and volunteers. I understand and agree that by signing this agreement, I am giving up my (or the minor for whom I sign) right(s) to make any claim against Santa Cruz Learning Center, its agents, employees, volunteers and independent contractors, including the right to sue them, for bodily or personal injury or property damage or any other loss that I might suffer while using Santa Cruz Learning Center services, except as limited by law.

Clear
Name of person signing this registration form

First NameLast Name
Should be Empty:

After School Adventures Camp Registration for the 2023-2024 School Year

Information for Parent or Guardian 1

Information for Parent or Guardian 2

Participant Information

Emergency Contact

Financial Commitment Form

Medical Insurance Information

Health Information

RELEASE SECTION