Clone of 2020 Xavier Summer Camp Registration Form

Xavier Summer Camp Registration Form
CHILD INFORMATION:
Child Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
Enter the grade level your student will be in the fall
Name of School*
Gender*

FemaleMale
T-Shirt*
CAMP INFORMATION:
What week would you like to attend camp?

Week 1: June 8 - June 12Week 2: June 15 - June 19Week 3: June 22 - June 26Week 4: June 29 - July 2Week 5: July 6 - July 10
Selected options of What week would you like to attend camp?
Select the Camp you want to attend on Week 1: June 8 - June 12

All Sports - (Pre-K to 5th Grade) - 9am to 2pm - $150Dance Camp - (Pre-K to 5th Grade) 9am to 2pm - $150Baseball Camp - (2nd to 8th Grade) - 8am to 11am - $75Softball Camp - (2nd to 8th Grade) - 8am to 11am - $75"X"Plore Camp - (5th to 8th Grade) 9am to 2pm - $150
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name #1*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
EMERGENCY CONTACT
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*

Area CodePhone Number
Is Student Insured*

YesNo
Special Notes about Student
Select the Weeks you want to attend XPlore Camp*

Purple Week: June 10 - June 14 - $150Orange Week: June 17 - June 21 - $150Yellow Week: June 24 - June 28 - $150Blue Week: July 1 - July 3 (3 Day Camp) - $90Green Week: July 8 - July 12 - $150Lunch ONLY
Select 5 activities to do for Purple Week*

3D Design & PrintingAnimationBoard Game ChallengeCelebrating the Short Story / English PrepCodingDance - Hip HopGuitarImprovisationIntro to Crime Scene InvestigationLeadership ChallengeMovie Making and Digital Story TellingMusic ProductionNumber Wizards / Algebra PrepOutdoor ChallengePainting and DrawingPassport Around the WorldPianoRoboticsSinging and VoiceSpanish Conversation / Hablando con Amigos
Select 5 activities to do for Orange Week*

3D Design & PrintingAnimationBoard Game ChallengeCelebrating the Short Story / English PrepCodingDance - Hip HopGuitarImprovisationIntro to Crime Scene InvestigationLeadership ChallengeMovie Making and Digital Story TellingMusic ProductionNumber Wizards / Algebra PrepOutdoor ChallengePainting and DrawingPassport Around the WorldPianoRoboticsSinging and VoiceSpanish Conversation / Hablando con Amigos
Select 5 activities to do for Yellow Week*

3D Design & PrintingAnimationBoard Game ChallengeCelebrating the Short Story / English PrepCodingDance - Hip HopGuitarImprovisationIntro to Crime Scene InvestigationLeadership ChallengeMovie Making and Digital Story TellingMusic ProductionNumber Wizards / Algebra PrepOutdoor ChallengePainting and DrawingPassport Around the WorldPianoRoboticsSinging and VoiceSpanish Conversation / Hablando con Amigos
Select 5 activities to do for Blue Week*

3D Design & PrintingAnimationBoard Game ChallengeCelebrating the Short Story / English PrepCodingDance - Hip HopGuitarImprovisationIntro to Crime Scene InvestigationLeadership ChallengeMovie Making and Digital Story TellingMusic ProductionNumber Wizards / Algebra PrepOutdoor ChallengePainting and DrawingPassport Around the WorldPianoRoboticsSinging and VoiceSpanish Conversation / Hablando con Amigos
Select 5 activities to do for Green Week*

3D Design & PrintingAnimationBoard Game ChallengeCelebrating the Short Story / English PrepCodingDance - Hip HopGuitarImprovisationIntro to Crime Scene InvestigationLeadership ChallengeMovie Making and Digital Story TellingMusic ProductionNumber Wizards / Algebra PrepOutdoor ChallengePainting and DrawingPassport Around the WorldPianoRoboticsSinging and VoiceSpanish Conversation / Hablando con Amigos
Would you like to purchase lunch?*

YesNo
Menu includes:

• Monday - Togo's (Sandwich)
• Tuesday - KFC (Chicken Strips)
• Wednesday - Panda Express (Orange Chicken Bowl)
• Thursday - Little Caesars (Pizza)
• Friday - Hamburger or Hot Dog
Select the Weeks you want to purchase LUNCH*

LUNCH Orange Week: June 17 - June 21 - $25LUNCH Yellow Week: June 24 - June 28 - $25LUNCH Blue Week: July 1 - July 3 (3 Day Camp) - $15LUNCH Green Week: July 8 - July 12 - $25
Summer Xplore Camp Terms and Conditions*

I agree
2019 Xavier Summer Program Terms and Conditions
BY CHECKING THE BOX ABOVE I/WE ACKNOWLEDGE I/WE HAVE READ THIS PARTICIPATION, ASSUMPTION OF RISK, WAIVER AND RELEASE OF LIABILITY, AND INDEMNIFICATION AGREEMENT; FULLY UNDERSTAND ITS TERMS; UNDERSTAND THAT I/WE HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT; AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT (OTHER THAN THE OPPORTUNITY TO PARTICIPATE IN XAVIER’S 2018 SUMMER PROGRAM), ASSURANCE OR GUARANTEE BEING MADE TO ME/US. I/WE INTEND MY/OUR SIGNATURE(S) TO EFFECT A COMPLETE AND UNCONDITIONAL RELEASE AND WAIVER OF ALL LIABILITY, INCLUDING ANY NEGLIGENCE OF THE RELEASEES IDENTIFIED IN THIS AGREEMENT, AND TO INDEMNIFY THE RELEASEES, TO THE GREATEST EXTENT ALLOWED BY LAW.
Choose the method of payment*

Cash / CheckCredit Card
Admin Password*
For cash payments, please see Mrs. Coie at the Front Desk or Mrs. Gitmed in the Business Office to complete your purchase and turn in the money.
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Xavier College Prep

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Xavier Summer Camp Registration Form

CHILD INFORMATION:

CAMP INFORMATION:

PARENT/GUARDIAN INFORMATION:

EMERGENCY CONTACT

Credit Card