Summer Camp Enrollment Form

Summer Camp Registration 2019
CAMPER INFORMATION:
Camper Name *

First Name Last Name
Birth Date *

Month Day Year
Grade (FALL 2019) *
Name of School *
Primary Parent/Guardian Information
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
Alternate Parent/Guardian Information
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area Code Phone Number

ADDITIONAL INFORMATION
Physician Name

First Name Last Name
Physician Phone Number

Area Code Phone Number
Dentist Name

First Name Last Name
Dentist Phone Number

Area Code Phone Number
Medical Concerns
Does your child take medication regularly? *

Yes No
If your child requires medication regularly, what is this medication and when is this medication administered?
Does this camp participant have allergies to bee or wasp stings? Please give details in the space provided. *
Does this camp participant have any food allergies, sensitivities? Please give details in the space provided. *
Does this camp participant have any behavioral or medical conditions that we should know about? Please give details in the space provided. *

Permissions Section
I give permission for my child, to wear sunscreen. I understand that I will provide sunscreen with my child’s name clearly printed on the bottle. I may apply sunscreen on my child before they come to the Center, and will inform the teacher(s)if this is the case. The teachers have my permission to reapply sunscreen as needed throughout the day. *

Please allow my child to apply his/her own sunscreen, as needed during camp. Please apply sunscreen on my child as needed.
We take photos throughout the week to make photo albums on the last day of each week. Some of these photos are so great we want to post them on social media. Do we have your permission to publicly post a photo of your child?

Yes No
I hereby enroll my child in Santa Cruz Learning Center Summer Camp. In signing this application, I certify that my child is healthy and free of problems that could adversely affect their experience or that of other campers at Santa Cruz Learning Center Summer Camp.I agree to pay the balance of camp fees on or before June 1, 2019. I understand that reserved space may not be held past June 1, 2019 without full payment. A full refund is available if cancelled by May 1, 2019. A full refund less a $50 deposit (per session, per camper) is available if canceled before June 1, 2019. No refunds if canceled after June 1, 2019. ALL CANCELLATIONS MUST BE RECEIVED IN WRITING.I grant permission for the applicant to participate in all planned camp activities. I hereby grant Santa Cruz Learning Center Summer Camp and its agents full authority to take whatever actions they deem necessary regarding my child’s health and safety, and I fully release Santa Cruz Learning Center Summer Camp from any liability in connection there within. In the event of an emergency, I understand that prudent attempts will be made to contact the undersigned immediately. I understand that I will be responsible for payment of all medical and medication bills.I understand that my child must comply with the camp’s rules and standards of conduct and that the organization may terminate my child’s participation in the camp program if they do not maintain these standards.Santa Cruz Learning Center Summer Camp often transports campers off of the learning center address to participate in activities. Camp participants may be transported within Santa Cruz County. If Santa Cruz Learning Center Summer Camp transports campers beyond Santa Cruz County lines, I will be given a separate permission form which I will decide to sign or not at that time.By signing below, I hereby give my permission for my child to be taken off site, supervised, and to take part in programs with the Santa Cruz Learning Center Summer Camp.I understand these risks and release Santa Cruz Learning Center Summer Camp, and the directors, trustees, officers, volunteers and employees ofSanta Cruz Learning Center Summer Camp, from all liability for damages or injuries resulting from camp activities, negligence or defects in the preparation, instruction, or equipment involved in camp activities in or around Santa Cruz Learning Center.Santa Cruz Learning Center is not responsible for lost, stolen, or damaged personal articles.I individually and corporately agree to hold harmless Santa Cruz Learning Center, its volunteers, agents, employees and officers irrespective of any negligent act or omission by Santa Cruz Learning Center Summer those individuals arising from or related in anyway to this Santa Cruz Learning Center program. Signature

Clear

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Summer Camp Registration 2019

CAMPER INFORMATION:

Primary Parent/Guardian Information

Alternate Parent/Guardian Information

ADDITIONAL INFORMATION

Camp Choices

Permissions Section

PAYMENT INFORMATION