|
JUMPSTART
LEARNING CAMP APPLICATION |
||
|
REGISTRATION
FORM |
||
|
PARENT/GUARDIAN
INFORMATION (TYPE
IN FIELD) |
||
|
LAST
NAME: |
FIRST
NAME: |
|
|
LAST
NAME: |
FIRST
NAME: |
|
|
STREET: |
HOME
PHONE: |
|
|
CITY: |
BUSINESS
PHONE: |
|
|
STATE:
ZIP: |
EMAIL: |
|
|
|
CELL
PHONE: |
|
|
PARTICIPANT
INFORMATION |
|
|
|
LAST
NAME: |
FIRST
NAME: |
|
|
DATE
OF BIRTH:
AGE: |
SCHOOL:
GRADE: |
|
|
|
|
|
|
EMERGENCY
CONTACT INFORMATION |
||
|
NAME:
RELATIONSHIP:
PHONE: |
||
|
NAME:
RELATIONSHIP:
PHONE: |
||
|
MEDICAL
INFORMATION |
|
|
|
MEDICATION: |
|
|
|
ALLERGY: |
|
|
|
SIGN
UP & FEES: PLEASE CHECK
THE BOX FOR THE WEEK YOUR CHILD(REN) IS
ATTENDING. |
||
|
o
JUNE
16-20, 2008
$195.00**
|
RAIN
FOREST (SAFARI WEST $10 ENTRY
FEE) |
|
|
o
JUNE
23-27, 2008
$195.00 |
THE
CALIFORNIA MISSIONS (SONOMA MISSION IS FREE) |
|
|
o
JUNE
30-JULY 3, 2008
$195.00 |
THE
WILD WEST (MORNING STAR FARM
IS FREE) |
|
|
o
JULY
7-11, 2008
$195.00 |
TIDE
POOLS (POINT REYES SEASHORE
IS FREE) |
|
|
o
JULY
14-18, 2008
$195.00** |
SPACE
EXPLORATION (FIELD TRIP TO SRJC IS FREE) |
|
|
o
JULY
21-25, 2008
$195.00 |
FAIRYTALES
& MYTHS (FAIRYTALE TOWN $3.75 ENTRY FEE) |
|
|
EACH
CHILD NEEDS A BROWN BAG LUNCH EACH DAY |
||
|
PAYMENT
METHOD |
|
|
|
_____ CHECK _____CASH
_____CREDIT |
WEEKLY
FEE-
$195.00
|
|
|
_____
MC _____VISA |
|
|
|
CARD
NO.: |
|
|
|
EXPIRATION
DATE: |
|
|
|
NAME
ON CARD: |
|
|
|
SIGNATURE: |
|
|
|
CHECKS
AND CREDIT CARD CHARGES PAYABLE TO "JUMPSTART NETWORK" MEMO NOTE: "LEARNING
CAMP" |
||
|
RELEASE
OF PHOTOGRAPHS |
|
|
|
For
valuable consideration, the undersigned understands and agrees that
photographs or video recording may be taken during any JUMPSTART
|
||
|
LEARNING
CAMP activity and the undersigned hereby gives
permission to have photographs or videos taken and authorizes the
use |
||
|
and
reproduction of said photographs and videos by the JUMPSTART LEARNING CAMP
and JUMPSTART NETWORK. |
||
|
All
negatives and prints shall become the property of the JUMPSTART LEARNING
CAMP and JUMPSTART NETWORK. |
||
|
_____________________________________________
_____________________________________________________
________________ |
||
|
PARENT/GUARDIAN
NAME
PARENT/GUARDIAN SIGNATURE
DATE |
||
|
CONTACT
INFORMATION |
|
|
|
ABBIE
LANDIES
DIRECTOR |
TELEPHONE:
(415) 328-5054 |
|
|
|
||