Thve , is not affiliated 2015 AIM Summer Camp Program This program, while located at the University of Miami, is not affiliated, sponsored or endorsed by the University of Miami July 13h through July 24th, 2015 9:00 AM - 3:00 PM (There will be a charge of $20.00 per half hour for any pick-ups after 3:00 PM) REGISTRATION FORM Please PRINT Parent/Guardian: Relationship: Address: Phone: Email: Participant: Age: Emergency Contact: Relationship: Phone: T-Shirt Size Email: The summer program will be held at the University of Miami School of Architecture with off-site field trips and tours conducted on Wednesdays. Please complete this registration form as soon as possible; space is limited to 75 children. The AIA Miami Chapter is not responsible for transportation. Parents and/or guardians are responsible to transport AIM Camp participants to and from the University of Miami School of Architecture, all fieldtrips and tour locations. Lunch is responsibility of the AIM Camp participant. Cost: $225.00 for the two-week program – Attached please find the Credit Card Authorization Form Checks payable to: AIA Miami/AIM Summer Camp Program, 100 N.E. 1st Avenue – Suite 100, Miami, FL 33132 We will inform you of the Summer Camp’s Program as soon as we have detailed description of the classes that will be offered to the children, including the evening of the concluding Awards Ceremony and Event date, tour times and locations. (All information will be sent via email). Please sign below giving permission for the AIM camp participant to attend. We appreciate your support of our 2015 AIM Summer Camp. Signature of Parent or Guardian AIA Miami Chapter 100 NE 1 Avenue – Suite 100 – Miami, FL 33132 Phone: 305.448.7488 [email protected] @ MIAMI CENTER FOR ARCHITECTURE & DESIGN, INC. st 100 NE 1 Avenue, Suite 100 Miami, FL 33132 One Time Credit Card Payment Authorization Form Sign and complete this form to authorize AIA Miami to make a one-time debit to your credit card listed below. By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account. Please complete the information below: I ____________________________ authorize AIA Miami to charge my credit card (full name) account indicated below for _____________ on or after ___________________. This payment is for (amount) (date) _____________________________________. (description of goods/services) Billing Address ____________________________ Phone# ________________________ City, State, Zip ____________________________ Email ________________________ Account Type: Visa MasterCard AMEX Cardholder Name _________________________________________________ Account Number _____________________________________________ Expiration Date ____________ CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX) ______ SIGNATURE DATE I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.