HCTP Summer Camp Registration Form

2. Parent/Guardian and Emergency Contact Information
Parent/Guardian Name*

Last NameFirst Name
What is your relationship to the student*
Address (Pease enter home address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number (Cell if available)*
Please enter a valid phone number.
Confirm Phone Number (Cell if available)*
Please ensure this number matches the primary phone number above.
Can we use the above phone number to send text?*

YesNo
Parent Email*
example@example.com
Confirm Email *
example@example.com
The email fields must match.
Emergency Contact Name

Last NameFirst Name
Emergency Contact Info

Phone NumberEmail

3. Additional Information
a) Medical or Special Needs
Allergies or special medical needs (if applicable)
Does your child have an IEP?*

YesNo
b) Pickup Arrangements (only needed for children in 5th grade or below)
Will your child be picked up at the end of each class by 10:00am either by yourself, the emergency contact or an additional authorized person listed below?*

YesNo

Please complete the section below if you want anyone besides yourself or the emergency contact person to pick up your child.

	Relation	Name	Phone #
Person 1
Person 2

c) Deposit & Attendance
HCTP requires a refundable deposit of $100 per child for Math Tutoring and Coding classes. I understand my child(ren) must attend at least 6 of 8 classes to receive the $100 refundable deposit. Please bring cash, check or money order for your deposit on the first day of the class (October 20, Sunday). Please acknowledge by clicking "Confirm" below.*

Confirm
d) Enrollement process and Lottery
HCTP wants to treat all applicants fairly, and acceptance to its program is not first come, first serve. A lottery may determine acceptance if the number of applicants exceeds the number of openings. To complete the registration for my child, I understand that I must first apply, receive acceptance notice, send responses when requested, and pay the class deposit by the due date (the first day of the class - October 20). Please acknowledge by clicking "Confirm" below.*

Confirm

e) Schedule and Due dates

The enrollment schedule is shown below.

1. Registration	September 16 (Mon) - October 11 (Fri)
2. Acceptance/lottery result emailed to parents	By October 13 (Sun)
3. Deposit check due	October 20 (Sun)

f) Cancellation & Refund Schedule

Enrollment cancellations can be made by writing to contact@hctpedu.org. No cancellation is accepted after the first day of the class (October 20). I understand that HCTP will issue a refund for the deposit only when the request for cancellelation is received at the above email address by the first day of the class.

4. Authorization and Release
I, as the legal guardian of the student(s) named above, give him(them) permission to attend HCTP programs and participate in any related activities. I assume all risks and hazards incidental to the programs and transportation (if any), and do further hereby release, absolve and hold harmless HCTP and Hanaim Church and its trustees, officers, directors, teachers, volunteers, staﬀ in case of any incidents or injuries that may occur in relation to the camp and the students above. In the event of an emergency and all the guardians are not available, I give permission for the director or medical coordinator to give authorization for medical treatment. I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or videos of the student(s) registered above for publicity purposes. I understand that HCTP reserves the right to cancel or change its courses, programs, services, or schedule due to lack of enrollment or other necessary reasons.

By e-signing my name below, I, hereby, authorize and accept all of the information above to be true.
Parent/Guardian Name: *

First NameLast Name
Date*

MonthDayYear
Should be Empty:

1. Student Information