Harambee Summer Camp
June 22-August 7, 2015
REGISTRATION FORM
PARTICIPANT INFORMATION
Please type or print legibly.
Last Name:
Gender:  Female
First Name:
 Male
Age: _
___________
T-Shirt Size____________
School:
Grade attended year 2014-2015:_____________________
Home address:
City:
State/Province:
Postal/Zip Code:
Country:
Telephone:
cell:
Parent email:
Please list ADA Accommodations needed:
(Include area code with telephone)
Mother’s name:
Mother’s day phone #:
Father’s name:
Father’s day phone#:
Mother’s cell phone#:
Father’s cell phone #:
Person(s) authorized to pick up child:
_____________________________Relationship:___________________
_____________________________Relationship:____________________
Other dismissal arrangements_________________________
Emergency contact:
Relationship:
Phone #:
Specify any of your child’s health problems:
Is your child on any medication? No Yes If so, please specify:
Student Allergies________________________________________________________________
Student Medical Problems_______________________________________________________________
Doctor______________________________Phone number____________________________________
Insurance carrier______________________Policy number______________________________________
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REQUIRES PARENT’S SIGNATURE:
You have my permission, in the event of an emergency and in case we are unavailable, to authorize any
physician, nurse practitioner or medical personnel to examine, interview, test and if necessary, treat my
child_______________________________________________ as they may deem advisable.
Important Information
Lunch: If you will be sending your child’s lunch please be sure that your child’s lunch is clearly marked with
your child’s first and last name. Glass bottles/containers are not allowed.
DROP OFF AND PICK UP TIMES
Drop off time:
 7:30AM for Before Care day campers
 8:30AM for full day campers
 12:00PM for half day campers
Pick



up time:
3:30PM for all campers
6:00PM for After Care campers
A $1 fee will be charged for every minute late after a 10 minute courtesy wait.
Payments: Tuition may be paid by cash or by money order.
Make the money order payable to: Harambee Charter School. A 10% discount on tuition paid in full
by May 1,2015.
Camp Fees Include lunch and Camp T-Shirt
 Full day of camp $125/week
 2 children $100/week
 3 or more $75/week
Please indicate what session your child will
be attending.
Session 1- 6/22-7/3(Payment Due 6/12/15)


Half day of camp $75/Week
Before Care $6/a day $30/week
Session 2-7/6-7/17(Payment Due 6/26/15)


After Care $6/ a day $30/week
Before & After Care $50/week
Session 3- 7/20-8/7(Payment Due 7/13/15)
Registration fee: $25 per family due with Application
I understand that the first week’s balance is due by June 10. I also understand that there are no make-ups or
refunds for any days missed for any reason. I will do my best to bring my child to Harambee Summer camp
every day.
SIGNATURE OF PARENT OR GUARDIAN
DATE
Media Consent
I hereby give permission to Harambee Institute of Science and Technology Charter School to
photograph and/or videotape the student for educational or promotional purposes. ________ (Initial)
Contact Information
For more information, contact Mama Marika, Camp Director at
215-316-0057
Email: [email protected]
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PARENT STATEMENT
I hereby state that (camper’s name) ___________________________________________ is in good mental
and physical health condition to participate in the activities provided by Harambee Summer Camp .,
including but not limited to tumbling, and dance training, baseball, basketball, soccer and or competition. I am
fully aware that any activity involving motion, Harambee Summer Camp height or athletic activity creates
the possibility of serious injury. I hereby release ., its employee and its staff from liability to the above
named athlete, of the person claiming through him/her, arising from injury to the person or property of the
Harambee Summer Camp ,above named athlete occurring in the premises of including any event
sponsored or sanctioned by , and or travel to Harambee Summer Camp and from such activities.
I understand that Harambee Summer Camp, has the right to deny admittance to any student not meeting
the standards of the program as it sees fit. I also agree not to hold these parties responsible in the event that
my son/daughter/child engages in inappropriate conduct (including, but not limited to disruptive or volatile
behavior in or out of camp, etc.) or becomes involved in any activity or with any persons not associated with
Harambee Summer Camp, or its scheduled program and that Harambee Summer Camp , has the right
to send him/her home for inappropriate conduct. I further attest that the information contained in this
application is correct to the best of my knowledge. In addition, I have agreed to the policy and fee statement
and agree to comply.
Parent Signature_____________________________________________Date___________
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