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Registration Form for S.T.E.M. Camp (June 23-27, 2014)

To register, please complete and submit the following information.

CHILD'S INFORMATION
Child's Last Name:
Child's First Name:
Nickname:
Date of Birth:
Gender:
Street Address:
City:
State:
Zip:
Home Phone:
Current School:
Rising Grade Level:
Age at Camp:
T-shirt Size:
Does your child have any allergies (food or environment)?
Does your child need to take medication at camp?
PARENT/GUARDIAN INFORMATION
Parent's/Guardian's First Name:
Parent's/Guardian's Last Name:
Parent's/Guardian's Cell Number:
Parent's/Guardian's Work Number:
Parent's/Guardian's Email:
EMERGENCY INFORMATION
List two people to contact if parent(s) cannot be reached:

First Contact Second Contact
Name:

Name:
Relation to camper: Relation to camper:
Phone Number: Phone Number:
Person(s) authorized to pick-up child:
Person(s) NOT authorized to pick-up child (please enter "N/A" if this does not apply):
AGREEMENTS
  1. The Martinson Center for Mathematics and Science agrees to notify the parent(s)/guardian(s) whenever the child becomes ill and the parent(s)/guardian(s) will arrange to have the child picked up as soon as possible if so requested by the Martinson Center. In addition, the parent agrees to notify the Camp Director within 24 hours or the next business day after his/her child or any member of the immediate household had developed any reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases, which must be reported immediately.

  2. The parent(s)/guardian(s) authorize The Martinson Center for Mathematics and Science to obtain immediate medical care if any emergency occurs when the parent(s)/guardian(s) cannot be located immediately.**

If there is an objection to seeking emergency medical care, a statement should be obtained from the parent(s) or guardian(s) that states the objection and the reason for the objection.

Please enter your initials and today's date in the spaces provided below to verify that you have read and understand the information provided above and that the information you submit is accurate to the best of your knowledge.
Enter your initials here Today's date
DROP-OFF AND PICK-UP INFORMATION
No camper may arrive before 8:45 am or stay later than 3:15 pm. There is a late pick-up fee of $15.00 per 15 minutes (or part of 15 minutes) for campers picked up after 3:15 pm. This fee may be adjusted if parents are continuously late. Please note that local authorities will be called if parent/guardian or emergency contacts are not available during emergency situations or hours of camp operation have passed.
ENROLLMENT AND COST INFORMATION
Do you belong to any of the following:
The cost for this camp is $225. The registration deadline is May 15, 2014.
PAYMENT INFORMATION
Once you press the Submit button, you will be directed to a secure payment page on which to enter your credit card information. You will receive a confirmation receipt immediately upon submission and authorization of the charge.