Summer Camp Registration 2019
CAMPER INFORMATION:
Camper Name
*
First Name
Last Name
Birth Date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
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Day
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
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1975
1974
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1971
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1969
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1967
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1963
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1961
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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
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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.
*
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Camp Choices
SESSION 1: JUNE 10 - JUNE 14 MAD SCIENTIST LABORATORY
Full Day
Morning Half Day
Afternoon Half Day
SESSION 2: JUNE 17 - JUNE 21 PALEONTOLOGIST PARADISE
Full Day
Morning Half Day
Afternoon Half Day
SESSION 3: JUNE 24 - JUNE 28 CREEPY CRAWLY CREATURES
Full Day
Morning Half Day
Afternoon Half Day
SESSION 4: JULY 8 - JULY 12 WIND, WATER, WAVES
Full Day
Morning Half Day
Afternoon Half Day
Drop in Individual day
SESSION 5: JULY 15-JULY 19 AREA 51
Full Day
Morning Half Day
Afternoon Half Day
Drop In Individual Day
SESSION 6: JULY 22-JULY 26 SUPER SPORTS HERO SPECTACULAR
Full Day
Morning Half Day
Afternoon Half Day
Drop In Individual Day
SESSION 7: JULY 29-AUG 2 CSI TRAINING
Full Day
Morning Half Day
Afternoon Half Day
Drop In Individual Day
SESSION 8: AUG 5-AUG 9 HOGWARTS SCHOOL OF WITCHCRAFT & WIZARDRY
Full Day
Morning Half Day
Afternoon Half Day
Drop In Individual Day
SESSION 9: AUG 12-AUG 16 CARNIVAL AND CIRCUS TRICKS
Full Day
Morning Half Day
Afternoon Half Day
Drop In Individual Day
Camp T-Shirt Size
*
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
How did you hear about our camp? (select all that apply)
Flyer or poster
We have participated in SCLC activities before
My teacher, ES, consultant, advisor, etc.
A friend or family member
Facebook
Instagram
Twitter
Earth Day Booth
Google search
If an individual recommended you to SCLC, please let us know who it was so we can thank them.
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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
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PAYMENT INFORMATION
NAME OF INDIVIDUAL RESPONSIBLE FOR PAYMENT
First Name
Last Name
RELATIONSHIP OF RESPONSIBLE PERSON TO CAMPER
HOW WOULD YOU LIKE TO PAY FOR CAMP?
*
I would like to mail in a check or money order
I can pay now with a credit card
I need a little more time and I will pay 1 week prior to camp session start date. I will pay the $25 deposit now to save my spot until then.
If choosing Drop off or Individual Days, please note which days and dates you would like here. Then enter the quantity of day in the payment section
list dates or day here
My Products
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Deposit for Camp (if not paying today)
$
25.00
Week of Camp Full Day: $325 Regular Rate
$
325.00
Quantity
1
2
3
4
5
6
7
Week of Camp Half Day: $200 Regular Rate
$
200.00
Quantity
1
2
3
4
5
6
7
Week of Camp Full Day: $175 Reduced Rate
$
175.00
weeks
1
2
3
4
5
6
7
Week of Camp Full Day: $225 Reduced Rate
$
225.00
Quantity
1
2
3
4
5
6
Week of Camp Full Day: $275 Reduced Rate
$
275.00
Quantity
1
2
3
4
5
6
7
Week of Camp Half Day: $100 Reduced Rate
$
100.00
Quantity
1
2
3
4
5
6
7
Week of Camp Half Day: $150 Reduced Rate
$
150.00
Quantity
1
2
3
4
5
6
7
Extended Care Fee x Day
$
20.00
Quantity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
Item subtotal:
$
0.00
Drop In or Individual Day
$
65.00
Quantity
Drop in or Individual Day
$
45.00
Quantity
Total
$
0.00
Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Date
Postal Code
Submit Form
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