Clone of [Imported] Registration

Registration - Summer Camp

Annandale, VA Campus
Today's Date

MonthDayYear
MM-DD-YYYY
Father's First Name
Father's Last Name
Father's Phone
Please enter a valid phone number
Father's email
example@example.com
Mother's First Name
Mother's Last Name
Mother's Phone
Please enter a valid phone number
Mother's email
example@example.com

Preferred Addresses

For communications.
Preferred email*
example@example.com
Street Address
Street Address
City
State / Province
If state, use 2-letter abbreviation.
Postal / Zip Code
Country

Program permission

The undersigned does hereby give permission for my child(ren) to attend and participate in programs organized by the Center for Redemptive Education.
First Name*
Last Name*

Campers
Camper #1 First Name*
Camper #1 Last Name*
Camper #1 Age Group*
Camper #1 will attend:*

Week #1Week #2
#1 Notes:*
Please note any special concerns or information we should know about this student. If none, simply write "none."
Do you want to register another camper?*

YESNO

Camper #2 First Name
Camper #2 Last Name
Camper #2 Age Group
Camper #2 will attend:

Week #1Week #2
#2 Notes:
Please note any special concerns or information we should know about this student. If none, simply write "none."
Do you want to register another camper?

YESNO

Camper #3 First Name
Camper #3 Last Name
Camper #3 Age Group
Camper #3 will attend:

Week #1Week #2
#3 Notes:
Please note any special concerns or information we should know about this student. If none, simply write "none."
Do you want to register another camper?

YESNO

Camper #4 First Name
Camper #4 Last Name
Camper #4 Age Group
Camper #4 will attend:

Week #1Week #2
#4 Notes:
Please note any special concerns or information we should know about this student. If none, simply write "none."
Do you want to register another camper?

YESNO

Camper #5 First Name
Camper #5 Last Name
Camper #5 Age Group
Camper #5 will attend:

Week #1Week #2
#5 Notes:
Please note any special concerns or information we should know about this student. If none, simply write "none."

Photo Permission*
A YES answer indicates that the Center for Redemptive Education has my permission to use my child’s photograph publicly to promote the organization. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use. My child’s name will not be used in association with any photos, unless authorized by a parent.
Emergency Contacts
Emergency #1 First Name*
#1 First Name
Emergency #2 Last Name*
#2 Last Name
Emergency #1 Phone Number*
Please enter a valid phone number
Emergency #2 First Name
Emergency #2 First Name
Emergency #2 Last Name
Emergency #2 First Name
Emergency Contact #2 Phone Number
Please enter a valid phone number

Carpool Permissions
Carpool #1 First Name*
Carpool #1 Last Name*
Carpool #1 Phone*
Please enter a valid phone number
Carpool #2 First Name
Carpool #2 First Name
Carpool #2 Last Name
Carpool #2 Last Name
Carpool #2 phone
Please enter a valid phone number
Carpool #3 First Name
Carpool #3 First Name
Carpool #3 Last Name
Carpool #3 First Name
Carpool #3 phone
Please enter a valid phone number
Carpool #4 First Name
Carpool #4 First Name
Carpool #4 Last Name
Carpool #4 Last Name
Carpool #4 phone
Please enter a valid phone number

General Policies Waiver and Release

Agreement is required for enrollment.
Weather:
• Programs take place outdoors, as weather permits. Students should be prepared for any weather scenario, including rain, snow, cold, or heat.
Food:
• Children and staff will bring their snack and meal food from home. Sharing food is not permitted. When drinks or foods will be part of a group experience, the ingredients will be sent to parents of all involved students, for permission to partake. We do not hold class parties for students, but with permission, treats may be sent in to share.
Health:
• Students with a fever, vomiting, diarrhea, or other significant symptoms of illness may return to the program after none of these symptoms has occurred for 24 hours without mitigation by prescription or over-the-counter medicine.
• We encourage appropriately frequent hand-washing and other hygiene practices regularly.
Safety:
• Students will be officially checked in at the designated area, typically curbside, each morning upon arrival. Students will be released only to an individual who is officially listed on the carpool list each day. Any change to drop-off or pick-up schedule must be arranged by notifying the program office or lead instructor.
• Only children with the requisite Waiver/Release form(s) will be admitted to CRE programs.
• No adult may be in the bathroom while children are in the bathroom, unless a parent is accompanying his or her own small child. If adults use the bathroom, the outer door must be closed to indicate that students must wait until the adult exits the bathroom.
• Bathroom and classroom doors will be open at all times, unless the classroom door has a viewing window.
General:
• We do not use toys, candy, or other rewards to shape student behavior.
• We employ Redemptive Discipline and Redemptive Leadership principles in shaping our program culture.
• Further information about the approach and policies of the Center for Redemption can be viewed at www.RedemptiveEducation.org.
Agreement
A YES answer indicates that I agree to all of these General Policies.
General Policies Agreement*

Yes
Parent/Guardian Full Name*
Electronic Signature*

Yes

Communicable Diseases Waiver and Release

Agreement is required for enrollment.
In consideration of being allowed to participate on behalf of Scent of Water and related events and activities, the undersigned acknowledges, appreciates, and agrees that:
1. Participation includes possible exposure to both wild and domesticated animals (dependent on campus location), insects, various plants, and other wildlife. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; and,
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against risks in outdoor activities. If, however, I observe and experience any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and,
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS (Center for Redemptive Education) their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“RELEASEES”), WITH RESPECT TO ANY AND ALL ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
Communicable Diseases Waiver Agreement*

Yes
Parent/Guardian Full Name*
Electronic Signature*

Yes

Outdoor Risks Waiver and Release

Agreement required for enrollment.
In consideration of being allowed to participate on behalf of Scent of Water and related events and activities, the undersigned acknowledges, appreciates, and agrees that:
1. Participation includes possible exposure to both wild and domesticated animals (dependent on campus location), insects, various plants, and other wildlife. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; and,
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against risks in outdoor activities. If, however, I observe and experience any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and,
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS (Center for Redemptive Education) their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“RELEASEES”), WITH RESPECT TO ANY AND ALL ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
Outdoor Risks Waiver*

Yes
Parent/Guardian Full Name*
Electronic Signature*

Yes

Parental Consent and Liability

Agreement required for enrollment.
As the primary parent, (the Releasor), an agent for myself and family members, the Releasor, being of lawful age, in consideration of being permitted to participate in activities, run and/or operated by the Center for Redemptive Education (referred to furthermore as the Releasee), WAIVE, RELEASE, and DISCHARGE the Releasee, its owners, officers, directors, employees, members, agents, assigns, legal representatives and successors, and all business associates and partners involved in the presentation of the above noted activities including but not limited to churches or commercial facilities in the District of Washington, the State of Virginia, and/or the State of Maryland; and their owners, officers and employees, from all liability for or by reason of any damage, loss or injury to person and property, even injury resulting in the death of the Releasor and/or family members, which has been or may be sustained in consequence of the Releasor’s participation in the activity(s) described above, and notwithstanding that such damage, loss or injury may have been caused solely or partly by the negligence of the Releasee.

I hereby acknowledge and agree that I have carefully read this Waiver and Release agreement, that I fully understand same, and that I am freely and voluntarily executing same.
By signing this release I and my family members will be forever prevented from suing or otherwise claiming against the Releasee for any property loss or personal injury that I or my family members may sustain while participating in or preparing for the above noted activity(s). This agreement is effective for the entire duration of my participation with this group.

I have been given the opportunity and have been encouraged to seek independent legal advice prior to signing this Waiver and Release agreement. I understand that this Waiver and Release agreement is binding on me, my spouse, my heirs, my executors, administrators, personal representatives and assigns. This release contains the entire agreement between the parties to this release and the terms of this release are contractual and not a mere recital.
This Waiver and Release Agreement will be construed in accordance with and governed by the laws of the State of Virginia, and it is acknowledged by the Releasor to be as broad and inclusive as permitted by the laws of this jurisdiction.

For participants of minority age (under 18 at time of registration)

This is to certify that I, as parent/guardian, with legal responsibility for this participant, have read and explained the provisions in this waiver/release to my child/ward including the risks of presence and participation and his/her personal responsibilities for adhering to the rules and regulations for protection against communicable diseases. Furthermore, my child/ward understands and accepts these risks and responsibilities. I for myself, my spouse, and child/ward do consent and agree to his/her release provided above for all the Releasees and myself, my spouse, and child/ward do release and agree to indemnify and hold harmless the Releasees for any and all liabilities incident to my minor child’s/ward’s presence or participation in these activities as provided above, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent provided by law.

Assumption of Risk / Waiver of liability / Indemnification agreement

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP
SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IF FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Risk, Liability, Indemnification Agreement*

Yes
Parent/Guardian Full Name*
Electronic Signature*

Yes

Medical Form

Required for participation.
A CRE medical form must be completed and submitted for all children attending camp. If you have already submitted a CRE medical form for the current or upcoming academic year program, please indicate so below.

Otherwise, please visit this page (www.redemptiveeducation.org/register) and scroll down to click on the Medical Form button to complete the form after submitting and paying for your camp registration.
Medical form status:*

Yes-submitted previouslyWill submit after paying for registration
Payment and Refund Policy
If you choose to pay by PayPal, upon completion of this form, you will be redirected to PayPal.

You also may choose instead to pay by check.

I understand that payment is non-refundable, except as provided as follows:
1. If minimum enrollment is not reached for a weekly session, I will be eligible to receive a full refund of the payment I have made for that week.
2. In case of over-enrollment, CRE families enrolled in the academic year program receive enrollment priority. Paid registrants receive priority over unpaid.
All enrollment is at the discretion of CRE. If my child is not able to be enrolled in such cases, I will be eligible to receive a full refund for my registration payments made for that child.
Payment and refund policy: I understand and agree.*

Yes
Paying with PayPal
prevnext( X )
Camp Week One
$295 Quantity

Camp Week Two
$295 Quantity

Total

$0.00
Paying by Check
1. To arrive at the total fee: Multiply the number of children by the number of weeks by the weekly fee.
  1. Example: If Billy will attend two weeks and Sally one week, you would multiply 2 (children) x 3 (weeks) x fee per week = total fee.
2. Write that total on your check and include a note, "For summer camp." Make the check payable to and mail it to:
  
  Center for Redemptive Education
  8220 Little River Turnpike
  Annandale, VA 22003
Paying by check

I will mail a check immediately
Should be Empty:

Registration - Summer Camp

Preferred Addresses

Program permission

Campers

Emergency Contacts

Carpool Permissions

General Policies Waiver and Release

Communicable Diseases Waiver and Release

Outdoor Risks Waiver and Release

Parental Consent and Liability

Medical Form

Payment and Refund Policy