Summer Science Camp Online Registration

Registration and Release Form

Child Information

Name of camper: *

Age: *

Grade in Sept. 2011: *

Address: *

City: *

Postal Code: *

Email (for newsletters or student science events): *

Parent/Guardian/Emergency Contact/Authorized to pick up information

Parent/Guardian

Name: *

Relationship: *

Home (tel): *

Work (tel): *

Cell: *

Parent/Guardian

Name:

Relationship:

Home (tel):

Work (tel):

Cell:

Emergency Contact (authorized to pick up)

Name: *

Relationship: *

Home (tel): *

Work (tel): *

Cell: *

Emergency Contact (authorized to pick up)

Name:

Relationship:

Home (tel):

Work (tel):

Cell:

Medical Information/Special Notes

Care Card: * #

Doctor's Name:

Doctor's Phone:

Does your child (check all boxes that apply and please explain below):

have hearing problems

take medications

have learning disabilities

have speech/language problems

have vision problems

have any special custody arrangement

require a special diet/ allergies

have other health concerns

Please specify and comment on any above marked items:

Also note that we will not handle any medications.

Signature of parent/Guardian: *

Entering your name here represents your signature on this document.

Date: *

Promotion:

Please check if you DO NOT want your child in any promotional materials.

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Northwest Science & Innovation Society

Summer Science Camp Online Registration