Summer Camp Registration & Waiver
Complete this form to register your child for the Citizen Scientists: Into the Wild summer camp and provide required medical, emergency, consent information and payment. Limit 3 Campers per submission.
Camper(s) Information
Enter all Campers' information you are registering
Camper #1 Full Name
*
First Name
Middle Name
Last Name
T-Shirt Size (Camper #1)
*
Please Select
Youth XS
Youth S
Youth M
Youth L
Youth XL
Adult S
Adult M
Adult L
Adult XL
Grade Entering (Fall)
*
Gender
*
Please Select
Male
Female
Non-binary
Prefer not to say
Other
Camper #2 Full Name
First Name
Middle Name
Last Name
T-Shirt Size (Camper #2)
Please Select
Youth XS
Youth S
Youth M
Youth L
Youth XL
Adult S
Adult M
Adult L
Adult XL
Grade Entering (Fall)
Gender
Please Select
Male
Female
Non-binary
Prefer not to say
Other
Camper #3 Full Name
First Name
Middle Name
Last Name
T-Shirt Size (Camper #3)
Please Select
Youth XS
Youth S
Youth M
Youth L
Youth XL
Adult S
Adult M
Adult L
Adult XL
Gender
Please Select
Male
Female
Non-binary
Prefer not to say
Other
Grade Entering (Fall)
Parent/Guardian Information
Parent/Guardian Full Name
*
Relationship to Camper
*
Parent/Guardian Primary Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email
*
example@example.com
Emergency Contacts
Emergency Contact Full Name
*
Relationship to Camper
*
Emergency Contact Primary Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Authorized Pickup Person Full Name
Relationship to Camper (Authorized Pickup)
Phone Number (Authorized Pickup)
Please enter a valid phone number.
Format: (000) 000-0000.
Custody Restrictions
I have a custody order or legal restriction affecting pickup. I will provide a copy to camp staff before the first day.
There are no custody restrictions applicable to this camper.
Medical & Health Information
Physician / Pediatrician Name
Physician Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Food Allergies - Describe reaction and treatment for severe/anaphylactic allergies
Environmental Allergies - Describe reaction and treatment for severe/anaphylactic allergies
Insect / Sting Allergies - Describe reaction and treatment for severe/anaphylactic allergies
Medication Allergies - Describe reaction and treatment for severe/anaphylactic allergies
Other Allergies - Describe reaction and treatment for severe/anaphylactic allergies
List any prescription or over-the-counter medications your child takes regularly
Medical Conditions, Physical Limitations, or Special Needs
Does your child carry any of the following? Skip if not applicable.
EpiPen / epinephrine auto-injector
Inhaler
Other emergency medication
If 'Other emergency medication', please describe
Medical Authorization & Consent
I authorize camp staff to obtain emergency medical treatment for my child if necessary.
*
I authorize camp staff to obtain emergency medical treatment for my child if necessary.
Parent/Guardian Signature (Medical Authorization)
*
Printed Name of Parent/Guardian (Medical Authorization)
*
Date (Medical Authorization)
*
-
Month
-
Day
Year
Date
Waiver of Liability & Assumption of Risk
I have read and agree to the waiver of liability and assumption of risk.
*
I have read and agree to the waiver of liability and assumption of risk.
Parent/Guardian Signature (Waiver)
*
Printed Name of Parent/Guardian (Waiver)
*
Date (Waiver)
*
-
Month
-
Day
Year
Date
Outdoor Environment Acknowledgment
*
I understand and accept the inherent risks of outdoor activities and will prepare my child accordingly.
Camp Policies & Parent Expectations
*
I have read and understand the cancellation policy described above.
I have reviewed the behavioral expectations and understand the dismissal policy.
I have read and understand the payment policy and confirm my child's spot is reserved upon receipt of full payment.
Photo & Media Release
YES — I grant permission for photographs and video of my child to be used by the Science Literacy Project for educational and promotional purposes.
NO — I do NOT grant permission for my child's image to be used. I understand that staff will make reasonable efforts to exclude my child from published photos.
Camper's Name (Photo Release)
Additional Notes or Special Instructions
Final Agreement & Signature
Parent/Guardian Signature (Final)
*
Printed Name of Parent/Guardian (Final)
*
Date (Final Signature)
*
-
Month
-
Day
Year
Date
Camp Fee Payment
Your registration will not be complete until the payment is made.
Camp Session Selection
*
Please Select
Week 1 May 26-28
Week 2 June 2-4
Week 3 June 9-11
Week 4 June 16-18
Week 5 June 23-25
Full 5 Weeks Session
Submit Registration
Submit Registration
Camp Registration Fee
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Summer Camp Registration Week One - May 26-28
Fee for one camper for selected session(s).
$
295.00
Week 1
1
2
3
4
5
Item subtotal:
$
0.00
Summer Camp Registration Week Two - June 2-4
Fee for one camper for selected session(s).
$
295.00
Week 2
1
2
3
4
5
Item subtotal:
$
0.00
Summer Camp Registration Week Three - June 9-11
Fee for one camper for selected session(s).
$
295.00
Week 3
1
2
3
4
5
Item subtotal:
$
0.00
Summer Camp Registration Week Four - June 16-18
Fee for one camper for selected session(s).
$
295.00
Week 4
1
2
3
4
5
Item subtotal:
$
0.00
Summer Camp Registration Week Five - June 23-25
Fee for one camper for selected session(s).
$
295.00
Week 5
1
2
3
4
5
Item subtotal:
$
0.00
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