March Break Camp 2015
Monday – Friday 8 am to 5 pm (programming from 9 am – 4 pm)
MARCH BREAK DATES:
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TOPICS:
[ ] Birds & Bugs
[ ] Mad Messages
[ ] Cell City
[ ] The Organ Trail
[ ] The Scene of the Crime
Monday, March 16, 2015
Tuesday, March 17, 2015
Wednesday, March 18, 2015
Thursday, March 19, 2015
Friday, March 20, 2015
Cost: [ ] $50 per day (individual full days)
[ ] $195 for full week
[ ] $30 per Half day (individual half days)
[ ] Morning Session 8 am – 12 pm
[ ] Afternoon Session 1 pm – 5 pm
LOCATION:
[ ] Mad Science Lab
4026 Meadowbrook Dr, Unit 123, London
[ ] Stoneycreek Baptist Church
2225 Highbury Ave N, London
Camper Name:______________________________________________ Current Age:________ Gender: [ ] Boy [ ] Girl
Parent’s Name:______________________________________________ Email:_____________________________________
Home Phone:__________________________ Work Phone:_____________________ Cell/Other:_______________________
Emergency Contact (other than parents):____________________________________________________________________
Emergency Contact Phone:_______________________________________________________________________________
Child will be picked up by (name):_________________________________________________________________________
Amount Paid:________ Paid by: [ ] Cash
[ ] Cheque
[ ] Visa
[ ] Mastercard Office Use:__________
Credit Card Option – Credit Card Number:__________________________________________ Expiration Date:______
Cardholder Name (please print):____________________________________________________
Cardholder Signature:_____________________________________________________________
For health problems or other pertinent information, please note that health and medical information may be shared between Mad Science®
of London staff and camp Instructors. If your child has any health/medical condition (asthma, allergies, medication, special needs,
hyperactivity, etc.) that could affect your child/children during camp, please not below (you may attach a separate sheet of paper and attach
it to this application, if necessary).
Health Concerns:________________________________________________________________________________________________
______________________________________________________________________________________________________________
EpiPen Required: [ ] Yes [ ] No
Rescue Inhaler Required: [ ] Yes
[ ] No
Attach additional information if required.
Location of Emergency Supplies (EpiPen/Rescue Inhaler): [ ] Backpack [ ] Not on site
There is an element of risk inherent in participating in the scientific process, handling scientific materials and equipment. Mad Science® of London takes every precaution to ensure
the safety of its campers and staff. It is important for registered children and their parents to understand that if used improperly, and/or without Instructor supervision, certain
equipment and materials can be dangerous.
My child has permission to attend and participate in the Mad Science® Camp. I understand that failure to abide by policies and guidelines as outlined by my child’s Instructors may
result in the cancellation of this agreement, with only a partial refund. Further, I understand that damage to equipment and/or the facility due to reckless acts and/or deliberate
indifference by my child will be my financial responsibility.
In the event of an accident or illness affecting my child, Mad Science® of London and any hospital/physician has my permission to authorize on my behalf all procedures, including
transporting to hospital and necessary treatment therein, that may be deemed necessary for the care and well being of said child. Such action is to be undertaken only when I
cannot be contacted.
I acknowledge that Mad Science® of London and its representatives are not responsible for any injury, loss or damage of any kind sustained by any person while participating in the
Mad Science® Camp program. I will hold harmless and indemnify Mad Science® of London and its representatives from any liability as well as any claims arising from the damage to
the property of, or personal injury to, my child or any third party resulting from participation in the Mad Science® Camp program.
Please sign below to certify that your child is physically able to participate in all Mad Science® activities. Mad Science® of London assumes no responsibility for injuries or losses
caused by situations or inappropriate behaviour beyond our control. I understand that this is a legal agreement. I have read and understood all of the terms of this agreement, and
by signing this agreement voluntarily, I am agreeing to abide by its terms. I give Mad Science of London permission to contact me by email.
Parent Signature:________________________________________________________________ Date:______________________________