WATER WORLD, grades 5-6
April 19-24, 2015
Include these required forms to register:
 This registration form
 Medical release form
 Student Contract
 Scholarship form if applying
Name of student _________________________________________________ Gender (check one) ____ Male ____ Female
Parent/guardian email address (used for all communication, please print clearly) ___________________________________________
Mailing address _____________________________________________________________________________________
City ___________________________________________________________ State ____________ Zip _____________
Home phone __________________________________ Student’s cell phone _________________________________
Parent or guardian name ________________________________________ Cell phone ___________________________
Who will pick student up March 6? ________________________________ Cell phone ___________________________
Date of birth __________________
Name of chaperone _______________________________________
School _________________________________________________________
Meal choice
 regular
 vegetarian

 Nut allergy
Dairy intolerance
District ___________________________
 Seafood allergy
 Shellfish allergy
If sharing a room is an option, I would most like to share with _____________________________________________________________
Cost of session is $500, and includes tuition, room and board.
A $100 non-refundable deposit is required to register for the program. For scholarship applicants, the fee is $25.
Fees are due in full March 30, 2015. Partial refunds can only be made through March 30, 2015.
Scholarship funds are available: Download scholarship application and information at our website, www.centrum.org/admin/ and
return it with this registration form. Deadline to apply for a scholarship is March 9, 2015.
Check one:
_____ $500, paid in full
OR
Paid by check no. ________ , enclosed
_____ $100 deposit (remainder due 3/30/2015)
_____ I have enclosed a scholarship application with my $25 deposit
or
Visa/MasterCard ________________________________________________________________________________
exp date __________________ v-code _______ Signature _____________________________________
By registering for this workshop, I hereby grant permission to Centrum to use my likeness, now or in the future, on its World Wide Web site or for other
promotional uses (print or video) without further consideration, and I acknowledge Centrum’s right to crop or treat the image or likeness at its
discretion. I further agree to indemnify and hold Centrum and its photographers and/or videographers harmless from any claims.
Questions? Contact Martha Worthley, Program Manager, [email protected] or 360-385-3102 x120.
Please mail completed forms to CENTRUM, PO Box 1158, Port Townsend, WA 98368 ● Fax: 360-385-2470
When your registration is received, confirmation materials will be sent to you via email, followed by reminders with updates and what-to-bring list closer
to the start of the workshop. If you do not receive a confirmation email within a week of mailing this form, please contact Cenrum, [email protected] or
360-385-3102 x117.
Centrum MEDICAL RELEASE FORM: required for any student under 18 years of age
Workshop Attending: ________________________________________________________________
Name of student: ____________________________________________________________________
Date of birth: __________
Male / Female
Parent/Guardian names & contact numbers:
_______________________________________________________________
______-______-__________
_______________________________________________________________
______-______-__________
Will student bring a Cell Phone?
YES / NO
If yes - Students Cell Phone # _____-_____-____________
Emergency contact name & phone number: _____________________________
(if parent/guardian is not available)
_____-_____-____________
Allergies: Please list any allergies you have to medications, foods (i.e. seafood, nuts, etc.) insect stings or bug/animal
bites, or any other concerns we need to be aware of:
If you carry an EpiPen or allergy kit, please initial here if you authorize Centrum to administer the appropriate
medications:
___ YES ___ NO
Other instructions:
Medical Information:
Please list below any medical conditions (or special needs related to medical problems) that Centrum needs to be
aware of in order to insure a safe and comfortable experience:
Medications: Please list any medications you are currently taking (must be in original container):
Who do you want to administer the medication/s? Please check one:
_____ Chaperone
_____ Dorm Counselor
Date of last Tetanus Shot: ______________
Insurance Company and Policy Number:
__________________________________________________________________________
(Please send a copy of your insurance card with this form. It is very important to have this in case of an emergency.)
Subscriber Name/Relationship:
__________________________________________________________________________
Parents/Guardians: In case of medical emergency, I hereby authorize Centrum staff to act in their best judgment to seek
medical attention through appropriate means, including emergency room treatment, as deemed appropriate by attending medical
personnel. I also accept responsibility for expenses incurred through such treatment.
If this student has a headache or sustains a minor injury while at Centrum, please initial here if you authorize Centrum
to administer the appropriate over the counter medications: Tylenol (Acetaminophen), Advil (Ibuprofen), Benadryl,
Rolaids, or cough drops:
____ YES
____ NO
Other instructions:
____________________________
Parent/Guardian Printed Name
______________________________________
Parent/Guardian signature*
_________________
Date
*If parent/guardian chooses not to sign the medical treatment release for reasons of personal belief
it is necessary to return a written, signed set of instructions of what to do in case of medical emergency.
Return to: Centrum Registration, PO Box 1158, Port Townsend WA 98368
Fax: 360-385-2470
Centrum Student Contract
Required for all students under the age of 18 participating in Centrum Workshops
Name: ____________________________________________________________________________
Workshop Attending: _________________________________________________________________
Centrum’s student guidelines are designed to create a safe and inspiring environment for each student. You must sign
and agree to the following contract in order to participate. Centrum staff reserves the right to dismiss a student
without refund if s/he chooses to ignore any of the following rules. Here’s what you promise:
1.
I will attend all mandatory scheduled classes, workshops, evening presentations, rehearsals and dorm meetings.
2.
I will abide by the dorm curfew and wing curfew times. I will follow all rules explained to me by the Centrum Dorm
Counselors.
3.
I will remain at Fort Worden State Park for the full duration of the workshop, except for approved, workshop-related offsite events. I may leave campus only with the authorization of the Centrum Program Manager.
4.
If I become injured or ill, I will contact Centrum staff, who has access to First Aid kits and my medical release form.
5.
I will respect the privacy of male and female dorm wings. Common rooms may be used for social gatherings. I understand
that no overt or covert sexual behavior is accepted. This recognizes not only Centrum’s legal responsibility but also the
intent to be as inclusive as possible and courteous of people’s feelings regarding sexual display.
6.
I will not possess or use alcohol, illegal drugs or tobacco, while in attendance at the workshop. If I do possess or use
alcohol, illegal drugs or tobacco I understand that it will result in my immediate expulsion, without refund, from the
workshop.
7.
I understand that possessing weapons (real or toy), or physically or verbally threatening another person will result in
immediate expulsion without refund. Fireworks and lighters are prohibited.
8.
I will respect the privacy and property of other participants. I will be responsible for my own belongings and will not hold
Centrum liable for any loss.
9.
I will respect the facilities and the grounds of Fort Worden State Park, comply with State Park regulations and obey all
posted signs. In the event of any damage to buildings, furnishings, or other property, I and/or my parents or guardians
will cover the actual cost of clean-up, repair, or replacement. I will take care of my dorm room and classrooms and help
keep the dining area and Park grounds clean.
10. I will have no visitors who are not official participants in the workshop (they must have an official nametag to be in the
dorms or classrooms). The exception would be for the student presentations, which are open to friends and family.
11. I will not hesitate to bring any problem to the attention of Centrum staff - instructor, dorm counselor, program manager,
office staff. I have read the rules and regulations for Centrum workshops and I promise to behave in accordance with
them.
__________________ ____________________________________
Date
Student signature
______________________________________
Student Printed Name
Parents: Please sign below to acknowledge that you have read the above regulations. Students who choose to break
their promise may be expelled without refund.
__________________ ____________________________________
Date
Parent / Guardian signature
____________________________________
Parent / Guardian Printed Name
Please return to Centrum Registration, PO Box 1158, Port Townsend WA 98368
YOU MUST BE REGISTERED FOR A CENTRUM WORKSHOP BEFORE APPLYING
FOR A SCHOLARSHIP.
Please submit a completed registration form with this application.
CENTRUM’S SCHOLARSHIP APPLICATION
SECTION A: BASIC INFORMATION
Secondary Phone:
Date of Birth:
 Yes, and I received a scholarship
 Yes, but didn’t receive a scholarship
 No, I haven’t attended this workshop previously
1. How did you learn about these scholarships? (Please check and describe all that apply.)
 School Counselor
 Teacher
 Word of Mouth (i.e.
friend)
 Centrum Staff
 Website:
 Newspaper/Magazine:
 Organization:
 Other:
2. This information is optional, but helps ensure that scholarships reflect the diversity consistent with our
program goals. Please note that more than half of our scholarship funds are for culturally diverse participants.
In many cases, we have funds specifically addressing the items below.
Racial/Ethnic Identity:
Anything else we should take
into account, i.e. you live in a
culturally underserved area,
sexual orientation,
mobility/disability issues,
etc.?
YOU MUST BE REGISTERED FOR A CENTRUM WORKSHOP BEFORE APPLYING
FOR A SCHOLARSHIP.
Please submit a completed registration form with this application.
SECTION B: FINANCIAL INFORMATION
Annual Household Income: $ __
Number of people in household:
Taking into account tuition, room, board, how much can you
afford to pay to attend this workshop?
I can pay: $ _________________
(Please enter a specific dollar amount)
K-12 students: do you qualify for free or reduced lunches at
school?
 Yes, free
 Yes, reduced
 No
Please use this space to briefly explain any special financial circumstances:
SECTION C: WORKSHOP INFORMATION (use additional page if necessary)
Please tell us why you want to attend this workshop, what you hope to get out of the experience:
Please tell us how long you have been interested in this area of art and/or science, which artists or scientists
inspire you, and why:
END OF
APPLICATION
END OF
APPLICATION