Summer 2019: High School Registration Form

Student Name

First Name Middle Name Last Name

Student's Grade Level Fall 2019

How Did You Learn About Us?

Does this student have any learning differences? If so, please elaborate below.

Birth Date

Month Day Year

High School Name

Student E-mail

Primary Parent Phone Number *

Area Code Phone Number

Student Phone Number

Area Code Phone Number

Parent Phone Number *

Area Code Phone Number

Does this student have any medical issues that we should be made aware of? If yes, please elaborate below or, if not, enter "no" below. *

Doctor or Clinic Name

Doctor or Clinic Phone Number

Doctor or Clinic Address

Medical Insurance Name, Participant Number and Group Number (or enter "none")

Is There Anything You Would Like to Add About This Student or This Course?

Person Responsible for Payment

First Name Last Name

Email of Person Responsible for Payment

example@example.com

Click to edit this text...

Billing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Payment Options

SAT/ACT Course $ 500.00

My Tribe: Female Empowerment $ 180.00

Total $ 0.00

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

I hereby enroll my child in a Santa Cruz Learning Center Summer Program. In signing this application, I certify that my child is healthy and free of problems that could adversely affect their experience or that of others at Santa Cruz Learning Center. I agree to pay the balance of cam 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 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 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 center's rules and standards of conduct and that the organization may terminate my child’s participation in the summer program if they do not maintain these standards. I understand these risks and release Santa Cruz Learning Center, and the directors, trustees, officers, volunteers and employees of Santa Cruz Learning Center, 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 at 501 Cedar Street, Santa Cruz, CA 95062. 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 those individuals arising from or related in anyway to this Santa Cruz Learning Center program. Signature *

Clear

Summer Course Registration Form

Medical Information