2015 BOSS CAMP July 27 31 BASIS Tucson Organizational & Study Skills Camp Child’s name: ____________________________________________________ 15/16 Grade: ___________________ Birth Date: ______________________ Gender: ______________________ Main Phone: ______________________ Home Address: ____________________________________________________________________________________ Parent Email: ____________________________________________________________________________________________ Please select the session your child will be attending each day: □ Session 1 8:30-10:30am □ Session 2 11:00-1:00pm □ Session 3 1:30-3:30pm SMART for Charters ID #: ______________________________ *$150 registration fee must be payed through your SMART for Charters account once you have been billed. Tax Credit Designation: □ Full Amount □ $___________ □ No, thank you PARENT CONTACT: 1. Parent Name: __________________________________________________ Relation: ___________________________ Work Phone: ____________________ Cell Phone: ____________________ Home Phone: ____________________ 2. Parent Name: __________________________________________________ Relation: ___________________________ Work Phone: ____________________ Cell Phone: ____________________ Home Phone: ____________________ EMERGENCY CONTACT: (In case of illness, accident, or emergency if parents can not be reached) 1. Name: ____________________________________ Relation: _________________ Phone: _________________ 2. Name: ____________________________________ Relation: _________________ Phone: _________________ Any allergies or physical restrictions? □ Yes □ No If yes, please specify: _________________________________________________________________________________ ____________________________________________________________________________________________________ Child’s Doctor: ___________________________________ Phone Number: _______________________________________ By signing below I confirm that all of the above information is correct. In case of emergency, every effort will be made to contact the parents, the emergency contacts and doctors listed. Failing to contact any of these, I give my permission to the school to call a physician or hospital and secure proper emergency treatment while efforts to locate parents continue. By signing below I agree to have my SMART for Charters account billed for this transaction and agree to pay the amount IN FULL by participants first session. By signing below I allow BASIS Schools, Inc. and BASIS.ed their successors, and their assignees the right to record the image and/or voice and use the artwork and/or written work of my child on videotape, film, in photographs, digital media, and in any other form of electronic or print medium and to edit such recording at their discretion. I further grant the right to use my child’s image and/or voice with or without their name on the internet, in brochures, and in any other medium and hereby consent to such use. I hereby release BASIS Schools, Inc. BASIS.ed, their successors, and their assignees from all claims, damages, demands, costs, expenses, and liabilities whatsover in connection with the above. Arizona Tax Credit: The tax credit designation above cannot be modified one this Extracurricular Payment Form is submitted. According to the Arizona Law (A.R.S.) § 43-1089.01, the total amount of credit for the taxable (calendar) year for contributions made to a public school in the State supporting extracurricular activities or character education programs is limited. Taxpayers who file a tax return as single or head of household can contribute up to $200. For married couples filing a joint tax return can contribute up to $400. If married taxpayers file separate returns, each spouse can claim up to $200 on each return. Contributors should review the Arizona Tex Credit Instructions or the Tax Credit Commonly Asked Questions for further information. Parent Signature: ___________________________________________ Date: ______________________________________