Summer Course Registration Form
Register for SCLC courses for Summer 2019
Student Name
First Name
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Year
High School Name
Student E-mail
Primary Parent Phone Number
*
-
Area Code
Phone Number
Student Phone Number
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Area Code
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Parent Phone Number
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Area Code
Phone Number
Medical Information
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
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( X )
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
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