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.
Please fill out a separate form for each participant!
Camper's First Name
Camper's First Name
Camper's Last Name
Camper's Age
Camper's Gender
Parents Information
and Emergency Contact
Parent/Guardian Contact
*
Emergency Contact
*
Medical & Health Information
Physician / Pediatrician Name
Physician Phone
Please enter a valid phone number.
Format: (000) 000-0000.
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
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
Review the full waiver
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
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 Registration Fee (Your registration will not be complete until the payment is made)
*
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Summer Camp Registration Week One - May 26-28
Fee for one camper for selected session(s).
$
275.00
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).
$
275.00
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).
$
275.00
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).
$
275.00
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).
$
275.00
Week 5
1
2
3
4
5
Item subtotal:
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit Registration
Submit Registration
Should be Empty: