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 Page 15 – Summer Camp 15 REGISTRATION & PERMISSIONS FORM (Page 1) RESERVE YOUR SPACE FIRST! Contact [email protected] -­‐ 407-­‐422-­‐8755 to confirm your space before submitting your payment STUDENT Name___________________________________________________ Age____________ Gender: M  F  Date of Birth______/______/______ Ethnicity _____________________ Current school_________________________________ Grade ______________ Free/Reduced lunch?____________ PARENT or GUARDIAN Name(S) ______________________________________________________________________ Street Address__________________________________________ City, State, Zip _____________________________ Home Phone: ( )_________________________________ Cell: ( )____________________________________ Student Email Address:______________________________ Parent Email Address:____________________________ EMERGENCY INFORMATION & FIELD TRIP RELEASE (initial each box, fill in each line) Allergies/Medications:_____________________________________ Special Needs:___________________________________________ Physician’s Name: _____________________________________ Physician’s Phone: ( )_____________________________________ Any activities in which your child is UNABLE to participate:_______________________________________________________________  I do hereby give consent for the child named above to participate in scheduled on-­‐site experiences and off-­‐site fieldtrips as part of this program. Further, I give my consent to Urban Think Foundation, Page 15 or its representative(s) to acquire emergency medical treatment for my child from competent medical personnel/facilities should that become necessary for any reason.  In order to expedite the care of my child named above, I give my permission for the appropriate medical personnel and staff to initiate treatment immediately upon arrival at the appropriate facility. I agree to be financially responsible for my child’s treatment. I also request that I (or the alternative emergency contact person listed) be notified of my child’s condition and admission as soon as possible. ALTERNATE CONTACT NAME: _________________________________________ PHONE:______________________________  In case of minor accident or illness, I request that the Program Representative contact me. If I am unable to be reached, I request that one of the persons listed on this form be contacted to care for my child.  In the event of a life-­‐threatening accident or illness, I understand that a Program Representative may contact 911 services immediately. I agree to be financially responsible for my child’s care and treatment. DEPARTURE / PICK-­‐UP AUTHORIZATIONS Authorization to Sign Out: Besides those designated above, the following people are authorized to sign my child out of the program: (ID is required) 1. NAME______________________________________________PHONE________________________________ 2. NAME______________________________________________PHONE________________________________  (Initials) WALK OUT / BIKE RELEASE: Page 15 staff has my permission to release my son/daughter to walk out at the end of each day. By my signature below, I agree that I will not hold Urban Think Foundation, Page 15 or its representatives responsible for my child once he/she has been appropriately released from daily activities. By my signature below, I do hereby state that I am the Parent or Legal Guardian of the child named on this form. Further, I do hereby consent and agree to all stipulations initialed above. Signature of parent or Legal Guardian_____________________________________________________ Date:______________________
Page 15 – Summer Camp 15 REGISTRATION & PERMISSIONS FORM (Page 2) RESERVE YOUR SPACE FIRST! Contact [email protected] -­‐ 407-­‐422-­‐8755 to confirm your space before submitting your payment SELECT SIGN UP OPTION: STUDENTS AGES Week 1 2 & 3 graders Week 2 4 & 5 graders Week 3 6 – 8 graders Week 4 9 & 12 graders Week 5 2 & 3 graders Week 6 4 & 5 graders CAMP DATES nd
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Monday, June 08 – Friday, June 12; 9:00am – 12:30pm th
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Monday, June 15 – Friday, June 19; 9:00am – 12:30pm th
Monday, June 22 – Friday, June 26; 9:00am – 12:30pm th
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Monday, July 13 – Friday, July 17; 9:00am – 12:30pm nd
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Monday, July 20 – Friday, July 24; 9:00am – 12:30pm th
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Monday, July 27 – Friday, July 31; 9:00am – 12:30pm TUITION: LUNCH: SCHOLARSHIPS: Students are welcome to bring their lunches from home or may sign up for daily lunches from Page 15’s favorite local school lunch caterer, Wholesome Tummies. Optional camp lunches are $25/week. Limited number of scholarships are available in each week of camp. Full scholarships cover tuition, lunches, and supplies; requires a $20 refundable reservation deposit that will be returned to you on the 3rd day of camp. Priority is given to student's nominated by a teacher. If you require a scholarship to attend camp please contact Page 15 at [email protected]. REFUNDS: FULL TUITION (all weeks): $175 / student (not including lunch) FULL SCHOLORSHIPS (all weeks): $0 / student (includes lunch) Cancelling 1 week before: If you have already submitted your payment and need to withdraw your child from the program before the first day, a full refund will be applied, including $20 registration fee for scholarships. Cancelling after first visit: If a child leaves the program after the first day, you will be refunded 50% of your payment. No refunds are made after the second visit to the program. For scholarships: For cancellation you will be charged $20 registration fee. PLEASE SELECT ONE REGISTRATION OPTION:  TUITION ONLY = $175  TUITION + LUNCH = $200  SCHOLORSHIP REQUESTED = $20 refundable registration fee Cash / Checks / Credit Cards accepted. Please make checks payable to: Urban Think Foundation, Inc. and mail with permissions and scholarship applications to: PAGE 15  P.O. Box 533709  Orlando, FL 32853-­‐3709  AGREEMENT: By my signature below, I certify that I am the legal Parent/Guardian of the child registering and agree that I will not hold Urban Think Foundation, Page 15 or its representatives responsible for any injuries which may be incurred by my child in any or all activities at the Summer CAMP for which we are enrolling. I understand that Urban Think Foundation, Page 15 may not provide insurance for my child, and I am financially responsible for all treatment or medical care of my child. I understand that Urban Think Foundation and Page 15 reserve the right to limit participation of any child for disciplinary reasons or non-­‐payment of fees. I agree to allow my child to participate in all Page 15 programs and activities and to appear in person or in voice, video or photographic presentation for radio, television, website or print media reports and/or media campaign(s) resulting from participation in a Page 15 program and/or event. My child is required to abide by the policies and procedures of the Urban Think Foundation and Page 15 staff. I agree to payment and refund policies outlined above. Signature of Parent or Legal Guardian ______________________________________________________________________________Date_____________________________