Mad Science Camp

Posted on 05/08/2019





MAD SCIENCE CAMP REGISTRATION FORM

Please enroll my child in the following camp/s: 

                                  Harris-Jackson (6/3-6/7)                              Ritzman (6/10-6/14)  

                                  Seiberling (6/17-21)                                      Schumacher (6/24-6/28)

Children may attend any or all of the camps listed above. If you enroll your child, please ensure he/she attends each day.

Complete entire form and return to your child’s school office by no later than May 22.

Early registration is strongly encouraged. * Complete BOTH sides of this form.

 

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Camper’s Name: _____________________________________________________________

                                                           LAST                                                               FIRST                             

Grade Completing: ______________________      Date of Birth:  ______ / ______ / _______

 

Camper’s School: __________________________________________________________________

 

Name of Parent/s: ____________________________________________________________

 

Phone-Home:  (_____) _____-_________ Work: (_____) ______-__________ Cell: (_____) ______-_________

 

Address: ____________________________________________________________________

                                                            STREET                                                                 CITY                                      ZIP

 

E-mail Address: ____________________________________________________________________

 

I would like to receive a monthly Mad Science Newsletter via e-mail:   YES / NO

 

 

AUTHORIZATION FOR EARLY PICKUP (MUST HAVE ID TO PICKUP EARLY)

 

The following person/s are permitted to pick up my child after Mad Science camp:

 

 

Name                                         Relationship to Camper                         Telephone #

 

Name                                         Relationship to Camper                         Telephone #

 

Name                                         Relationship to Camper                         Telephone #

 

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T-SHIRT SIZE

 

Please indicate your child’s T-shirt size:

(We have limited quantities of each shirt size.  We will make every attempt to provide you with the size selected. 

However, once quantities are depleted we will provide the closest possible size to that which was selected.)

 

_____ YS      _____ YM    ____YL         ____AS        ____AM        ____AL

 

 

 

MEDIA RELEASE

 

 Mad Science HAS / DOES NOT HAVE my permission to photograph my child, _____________________________________________, during camp which may be utilized on

the Mad Science website, Facebook, and/or Twitter.  Parent/Guardian Initials: ______________

 

DISMISSAL PROCEDURES

Please check one of the following choices:

 

________ I will pick my child up in the front of the building at 3:00 PM promptly. Please note:  Children being picked up by an adult whether they are walking or a car rider should choose this option.

________ I understand that dismissal is at 3:00 PM for Mad Science Camp. I understand there are no crossing guards on duty at this time. My child has permission to walk home with no adult supervision at 3:00 PM

Medical Authorization Form

Complete BOTH sides of this form.

 

In the event of an emergency, the numbers and names of those listed below should be contacted in that particular order: (You are not required to have 4 people listed if you do not wish to. Include all possible telephone numbers where each person may be reached during

the hours of camp.  Please include at least one parent/guardian in this listing)

 

 

Name _______________________________________________________________________

 

Relation ______________________________    Phone _______________________________

 

Name _______________________________________________________________________

 

Relation ______________________________    Phone _______________________________

 

Name _______________________________________________________________________

 

Relation ______________________________    Phone _______________________________

 

Name _______________________________________________________________________

 

Relation ______________________________    Phone _______________________________

 

 

*List any health problems, medications or allergies:

________________________________________________________________________________________________________________________________________________________

 

There is an element of risk inherent in participating in the scientific process, handling scientific materials and equipment. We at Mad Science of Northeast Ohio take every precaution to ensure the safety of our campers and staff. It is important for registered children and their parents to understand that if used improperly, and/or without instructor supervision, certain equipment and materials can be dangerous.

 

Mad Science strives at all times to provide fun, safe science activities for all children. In an effort to fulfill this commitment, we ask that all children enrolled follow the basic guidelines established and explained the first day of camp. If necessary, Mad Science may ask that a child be removed from camp, and in such a case, a partial refund will be considered. We ask for your cooperation in the event that you are notified of discipline problems.

 

Please sign below to certify that your child is physically able to participate in all Mad Science activities. Mad Science of Northeast Ohio and all of its representatives assume no responsibility for injuries or losses caused by situations or inappropriate behavior beyond our control.   

 

My child has permission to participate in the Mad Science Camp.  I understand that failure to abide by the policies and guidelines as outlined by my child’s instructor may result in the cancellation of this agreement, with only a partial potential refund.  Further, I understand that damage to equipment and/or the facility due to reckless acts and/or deliberate indifference by my child will be my financial responsibility.

 

X_______________________________________________________________________

  Parent/Guardian Signature                                                                                          Date

 

In the event that reasonable attempts to reach parents/guardians at phone numbers listed above have been unsuccessful, I hereby give my consent for the transport and administration of any treatment deemed necessary by:

 

__________________________________________________________________________

Preferred Physician                                                                                          Preferred Physician Phone

 

__________________________________________________________________________

Preferred Dentist                                                                                             Preferred Dentist Phone

 

or by other licensed physician or the transfer of child to nearest appropriate hospital or emergency facility.  This authorization does not cover major surgery unless the medical opinions of two licensed physicians or dentists, concurring in the necessity for surgery, are obtained prior to performance of surgery.

 

 

X_________________________________________________________________________

  Parent/Guardian Signature                                                                              Date

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