Summer Learning Camp 23: Registration Parent / Guardian InformationName(Required) First Last Email(Required) Phone(Required)Camper's InformationCamper's Name(Required) First Last Camper's Date of Birth(Required) MM slash DD slash YYYY Camper's Grade Entering(Required)Gr. 5Gr. 6Gr. 7Gr. 8Gr. 9Gr. 10Camp(s) AttendingWeek #1: July 10th - July 14th AM - Elective ChoiceRobotics & EngineeringDigital Art & PhotographyS.A.T. Preparation - Reading, Writing, LanguageMusic Production & CompositionPM - Elective ChoiceFitness & SportsRobotics & CodingWeek #2: July 17th - July 21th AM - Elective ChoiceRobotics & EngineeringS.A.T. Preparation - Reading, Writing, LanguageDigital Art & PhotographyMusic Production & CompositionPM - Elective ChoiceRobotics & CodingFitness & SportsWeek #3: July 24th - July 28th AM - Elective ChoiceRobotics & EngineeringS.A.T. Preparation - Reading, Writing, LanguageDigital Art & PhotographyMusic Production & CompositionPM - Elective ChoiceFitness & SportsRobotics & CodingWeek #4: July 31th - August 4th AM - Elective ChoiceRobotics & EngineeringS.A.T. Preparation - Reading, Writing, LanguageDigital Art & PhotographyMusic Production & CompositionPM - Elective ChoiceFitness & SportsRobotics & CodingEmergency Contact Information Name Relation PhoneDoes your child need to take a prescription or over-the-counter medication during camp hours?(Required) Yes No If yes, please list medications your child will be taking during camp hours.Will your child be self-administering any of these medications during camp?(Required) Yes No Allergies (please note whether the allergy is an ingested or contact allergy)Does your child carry an Epi-Pen?(Required) Yes No If yes, what is the allergy? Dietary Restrictions Emergency Medical InformationChild’s Physician/ Medical Care Provider & Phone Number Does your child require any special accommodations?(Required) Yes No If yes, please describe?Other Information You Think We Should Know(Relevant information may include: other medical conditions, mobility accommodations, special needs, child’s primary language if not English, etc.)Authorization for Camp ParticipationI authorize my child to participate in the camps listed above. I release Washington Preparatory School from any and all liabilities due to accidents, injury, or other harm to my child.(Required) Yes Photo/ Video ReleaseI grant permission to Washington Preparatory School to use, reproduce, and/or publish for promotion photographs and or film footage taken during camp. The use of these photographs and/or videos is strictly limited for use by the camp organizers. They will not be sold or reproduced for sale in any form. Yes No Authorization to Transport ChildI grant permission to Washington Preparatory School to transport my child in a company Bus or Van, driven by an individual authorized by Washington Preparatory School. (Required for the Sports & Fitness elective.) Yes No Behavior AgreementI understand that any child exhibiting behavior that may cause harm to themselves, other campers, or camp staff will be asked to leave the program. These behaviors include, but are not limited to, hitting, kicking, biting, sexual harassment, and/or possessing weapons or illegal substances.(Required) Yes Summer Learning Camp 23Total PaymentCredit Card(Required) American ExpressDiscoverMasterCardVisaJCBMaestroSupported Credit Cards: American Express, Discover, MasterCard, Visa, JCB, Maestro Card Number Expiration Date Month Month010203040506070809101112 Year Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name
