Student Science Camp Enrollment Form

Student Science Camp Enrollment Form

Complete this enrollment form to register the student for participation in the Student Science Camp. The person signing below certifies that the information provided is true and accurate, agrees to the terms and conditions of attendance, and authorizes the camp staff to act as described in the medical and emergency authorization provisions contained herein.

Camp Session Selection

Select the session(s) for which the student is enrolling:

Session A — Explorations (Week 1)

Session B — Discovery (Week 2)

Session C — Innovators (Week 3)

Student Information

Date of Birth:    Student ID:

Parent / Guardian Information

Relationship:    Primary Phone:

Emergency Contact & Medical Information

Relationship:    Phone:

Is the student currently under medical treatment that camp staff should be aware of? Yes No

Permissions, Authorizations and Policies

Emergency Medical Treatment Authorization: In the event of a medical emergency, I authorize camp staff to obtain medical care for the child named above. I authorize licensed physicians, emergency medical technicians, health care facilities, and medical personnel to provide necessary treatment, including hospitalization and anesthesia, as they deem necessary. I understand that I am responsible for all costs associated with such treatment.

Consent for Medication Administration: I authorize camp staff to administer non-prescription over-the-counter medication (such as acetaminophen or antihistamines) according to label directions if deemed appropriate. For prescription medications, I will provide written instructions and labeled containers; staff may administer medication as directed.

Transportation and Field Trip Consent: I authorize the student to travel on camp-sponsored transportation for field trips and local activities. I understand that all travel will be supervised by camp staff and that I will be notified in the event of an emergency.

Photo and Media Release: I grant    decline permission for the student to be photographed, videotaped or otherwise recorded during camp activities for promotional or educational purposes. Permission includes use in print, media, and program materials.

Code of Conduct and Discipline: The student is expected to follow camp rules and staff instructions. Failure to comply with safety rules or persistent disruptive behavior may result in dismissal from the program without refund. I agree to be responsible for costs and arrangements associated with early pickup if dismissal occurs.

Liability Release and Indemnification: By signing below, I release the camp, its employees, volunteers and agents from claims for personal injury, property damage or loss arising from ordinary negligence in connection with camp activities, except to the extent such claims arise from willful misconduct. I agree to indemnify and hold harmless the camp from claims brought by others related to the student's actions while participating in the program.

I acknowledge that I have read and understand the foregoing authorizations, releases, and policies. Initials:

Tuition, Fees & Refund Policy

Full payment due at enrollment

Payment plan (contact camp administration for schedule)

Refunds: Cancellations made more than 30 days prior to the start of the session are eligible for a refund less an administrative fee. Cancellations within 30 days are subject to partial or no refund as determined by camp policy. I acknowledge that applicable refund determinations are final and that financial responsibility for unpaid balances remains with the registrant.

I acknowledge the tuition and refund provisions above: Acknowledged

Certification

By signing below, I certify that: (1) I am the parent or legal guardian of the enrolled student or I am the student and at least 18 years of age; (2) the information provided on this form is accurate to the best of my knowledge; (3) I have reviewed and accept the camp’s health, safety and conduct policies as stated above; and (4) I authorize the camp to act within the scope of the consents given in this form.

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