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Monterey Bay Charter School
Summer Adventure Day Camp Payment
Camper’s Name: ___________________________________________________________ Grade Entering: ____________
Sibling Name: ______________________________________________________________ Grade Entering: ____________
Sibling Name: ______________________________________________________________ Grade Entering: ____________


Full Week @ $150.00
 June 15-19
 June 22-26
 June 29-July 3
 July 6-10
 July 13-17
 July 20-24
 July 27-31
 August 3-7
 August 10-14
Full Week Sibling @ $75.00
 June 15-19
 June 22-26
 June 29-July 3
 July 6-10
 July 13-17
 July 20-24
 July 27-31
 August 3-7
 August 10-14
Childcare Option

Day Use Only @ $35/day

August 3-7
 Monday date:___________________________
___________________________
August 10-14
 Tuesday date:
 Wednesday date: _______________________
 Thursday date: __________________________
 Friday date: _____________________________
Total: ________________

Full Week Sibling @ $75.00
 June 15-19
 June 22-26
 June 29-July 3
 July 6-10
 July 13-17
 July 20-24
 July 27-31
 August 3-7
 August 10-14
Camp Fee: $_________________
Morning childcare, 7:30am-8:00am: No charge
Afternoon childcare, 3:00pm-5:30pm: $10 per week X _____ week(s)
$_________________
Drop-ins welcome with 24 hours’ notice and paid in advance. Available only as space allows.
Payment
Total: $______________
 Paid in full: Date: __________________ Check Cash Credit Card
NOTE: Payment to register for Monterey Bay Charter School Summer Adventure Day Camp is non-refundable.
AGREEMENT FOR 2015 SUMMER DAY CAMP
ACTIVITY PARTICIPATION AND AUTHORIZATION FOR MEDICAL CARE
To the Director of Monterey Bay Charter School (School):
Camper’s Name: ______________________________________________________________________ Grade Entering in 2015-16: _________
has my permission to participate in School’s 2015 Summer Day Camp held at 1004 David Avenue, Pacific Grove, CA 93950.
PARENTS, PLEASE NOTE: It is a privilege, not a right, to participate in the 2015 Summer Day Camp; the privilege may be revoked at any
time. The acceptance and inclusion of camper is at the discretion of School and subject to program standards and criteria. Camper shall
comply with all applicable codes of conduct and maintain high ethical and moral standards.
ASSUMPTION OF RISK: By signature hereon, parent/guardian waives liability against and holds harmless the school and its board
members, staff, volunteers, agents; the Monterey County Office of Education; State of California; and further acknowledges that this
voluntary activity and/or transportation to and from (as applicable) may expose the camper to potential harm including injury or death. If
camper believes that an unsafe condition or circumstance exists with respect to activity(s), camper will discontinue participation and
immediately notify the Director or Administrative Coordinator. Camper shall not further participate until the unsafe circumstance is
remedied.
By signing below: (1) I am giving up substantial actual or potential rights in order to allow the student to voluntarily participate in this
activity(s); (2) I have signed this agreement with full appreciation and understanding of the risks inherent in the activity(s); (3) I have no
question regarding the intent of this agreement; (4) I, as parent or guardian, have the right to bind myself, the camper and any other family
member, representative, assign, heir, trustee or guardian to the terms of this agreement; and (6) I have explained this agreement to the
student, who understands his/her obligations hereunder.
• I give my child permission to participate in all camp activities.
• I give permission for my child to attend all trips and special programs during the camp season.
• I understand that Summer Adventure Day Camp is not responsible for the camper's personal property.
• Parent represents to the camp that the camper is fully able to participate in all camp activities.
• Camper will adhere to school behavior policies as provided separately.
AUTHORIZATION FOR
MEDICAL CARE
If it becomes necessary for my
child to have medical care while
participating in this activity, I
hereby give school personnel
permission to use their judgment
in obtaining medical care for the
child, and give permission to the
physician selected by school to
render medical care deemed
necessary and appropriate. I
understand that the school
carries student accidental injury
insurance in an amount limited to
$25,000 (applies excess of family
health insurance if applicable.)
Health Questionnaire
Camper’s Primary Address: _____________________________________________________________________
Student lives with: mother father step-mother step-father other:________________
Parent’s Name: _____________________________________________________________________________________
Address (if different) _____________________________________________________________________________
Home Phone ________________________Cell _______________________Work Phone ______________________
Parent’s Name: ____________________________________________________________________________________
Address (if different) _____________________________________________________________________________
Home Phone ________________________Cell _______________________Work Phone ______________________
Emergency Contacts Adults that may pick up my child or be called:
Name ________________________________________ Relationship ___________ Phone(s) __________________
Name ________________________________________ Relationship ___________ Phone(s) __________________
Yes No Does your child have any condition that limits participation in school activities?
Check here if medical treatment or prescriptions and/or over-the-counter medication are needed at the school.
If checked, a doctor’s authorization form is required.
Yes No Does your child take medication at home? If yes, what: ___________________________________________________________________
Does your student have any of the following? If yes, attach a detailed description with this form.
Asthma Diabetes Seizures Hearing loss Allergies Wears glasses Other: _____________________________________
X________________________________________________________Printed: ___________________________________________________ Date ___________________
Authorized Signature of Parent or Guardian