HCTP Summer Camp Registration Form

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

First NameLast 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

First NameLast 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 or 11:00am (depending on the class) 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 $100 refundable deposit per child for the classes. To receive the the refund, your child(ren) must attend at least 80% of the classes (e.g., 6 of 8, or 13 of 16 classes). The deposit is due by October 18 (Saturday) for Fall and December 27 (Saturday) for Winter, and you can either mail a check payable to HCTP (690 River Drive, Elmwood Park, NJ 07407) or pay via Zelle (contact@hctpedu.org) by that date. Click "Confirm" below acknowledge.*

Confirm
Financial Aid - Please check below if you need financial aid in the form of a reduced deposit ($50 instead of $100).

Financial aid requested
d) Enrollment process and Lottery
HCTP is committed to a fair application process, and acceptance is not based on a first-come, first-served basis. If the number of applicants exceeds available spots, a lottery may be used for selection. Classes may be cancelled if the minimum enrollment requirement is not met. To complete my child's registration, I understand that I must: - Apply; - Receive and respond to the acceptance notice/email; - Submit the class deposit by October 18 (Saturday) for Fall and December 27 (Saturday) for Winter. Please click "Confirm" below to acknowledge.*

Confirm

e) Schedule and Due dates

The enrollment schedule is shown below.

1. Application deadline	October 7 (Tuesday)
2. Acceptance/lottery result emailed to parents	October 9 (Thursday)
3. Deposit check due	October 18 (Saturday) for Fall and December 27 (Saturday) for Winter

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 26 for Fall Term or January 11 for Winter Term). 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.
g) Laptop
For classes that need a laptop (Plug and Make with Arduino or Exploring Math with GeoGebra), will your child be able to bring one?

YesNo (Note: HCTP will provide one for them to use in 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 below, I confirm my agreement to the terms above and certify that all information provided in this application is true and accurate.
Parent/Guardian Name: *

First NameLast Name
Date*

MonthDayYear
Should be Empty:

1. Student Information