Pinhole Photography Science Camp

Pinhole Photography Science Camp

www.skydome-education.org | skydome.edu@gmail.com
Student/Participant Name

First NameLast Name
Preferred Pronouns

he/him/hisshe/her/hersthey/them/their
Date of Birth

MonthDayYear
Date
Age
Fall 2024 Grade Level
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant Phone
Please enter a valid phone number.
Parent/Guardian #1 Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Alternative or Work Phone Number
Please enter a valid phone number.
Email
example@example.com
Relation to Participant
Parent/Guardian #2 Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Alternative or Work Phone Number
Please enter a valid phone number.
Email
example@example.com
Relation to Participant
Which parent(s)/guardian(s) does the participant primarily live with?

Parent/Guardian #1Parent/Guardian #2
Who is responsible for payment?

Parent/Guardian #1Parent/Guardian #2

Medical Release Information

The purpose of asking for this information about the participant is that in case of an emergency this can be shared with medical professionals in order for them to best expedite and determine treatment if they deem necessary.
Insurance Policy Number
Health Insurance Provider
Primary Physician
Physician Phone
Please enter a valid phone number.
Is the student/participant currently being treated for an injury or sickness, or taking medication? If yes, please explain.
Is the participant allergic to any type of food or medication? If yes, please explain.
Please list medical concerns that you would like the day camp staff to be aware of, as well as prescribed medications. Please include the condition, medication, and if medication administration is needed from camp staff.

Contact SkyDome Education LLC if you have questions regarding this registration form, or about the activities and details of this program before enrolling a participant. If there is joint-legal-custody of a minor age participant both parents/guardians are to review and sign this registration form or use two separate forms.
Parent/Guardian #1 Name*

First NameLast Name
I understand the nature of the activities of this science day camp operated by SkyDome Education LLC, and I have legal authority as parent/guardian to enroll Participant Name* in the July 8, 2024 to July 19, 2024 session.

Signature*
Today's Date*

MonthDayYear
Date
Parent/Guardian #2 Name

First NameLast Name
I understand the nature of the activities of this science day camp operated by SkyDome Education LLC, and I have legal authority as parent/guardian to enroll Participant Name in the July 8, 2024 to July 19, 2024 session.

Signature
Today's Date

MonthDayYear
Date
Payments are non-refundable; refunds will not be issued for a camper who does not fully attend, or withdraws from the camp program, or is removed from participation for behavioral/safety reasons. A photo-release, liability-waiver and additional documents and information will follow initial registration.
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Transportation