AHS Summer Camp Form

1. CAMPER’S INFORMATION HERE

Camper Information

MaleFemale

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Date of birth

Date

Age at time of camp

Grade entering this fall

The Camps you are interested in (check all that apply):

STEAM Camp “Groovy Machines” (July 1st - 4th (M-Th) 9:00 - 12:15 pm) - $400STEAM Camp “Space” (July 8th - 11th (M- Th) 9:00- 12:15 pm) - $400STEAM Camp “Amusement Park Challenge” (July 22th - 25th (M- Th) 9:00- 12:15 pm) - $400

List all Allergies and Dietary Restrictions

2. Parent/Guardian 1 Information:

(all correspondence and invoices will be sent to this person)

Name

First NameLast Name

DOB

Date

Occupation

Email Address

please be sure that your email address is valid. You will receive all correspondence to this email. Add “info@averroesinstitute.com” to your address book to ensure delivery.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Cell Phone

Please enter a valid phone number.

Relationship to Camper

Custodial Parent

YesNo

3. Parent/Guardian 2 Information:

(all correspondence and invoices will be sent to this person)

Name

First NameLast Name

DOB

Date

Occupation

Email Address

please be sure that your email address is valid. You will receive all correspondence to this email. Add “lmurphy@livingstonisd.com” to your address book to ensure delivery.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Cell Phone

Please enter a valid phone number.

Relationship to Camper

Custodial Parent

YesNo

4. Emergency Contacts and Authorized Pick Up Persons

(In addition to parents/guardians) Use this area to list the individual(s) we may contact in an emergency and/or you authorize to pick up your camper from

Name 1

First NameLast Name

Relation to Camper

Home Phone

Please enter a valid phone number.

Cell/Work Phone

Please enter a valid phone number.

Name 2

First NameLast Name

Relation to camper

Home Phone

Please enter a valid phone number.

Cell/Work Phone

Please enter a valid phone number.

5. How did you hear about AHS Summer Camp?

6. PARENTAL CONSENT TO TREATMENT / ACKNOWLEDGEMENT OF RECEIPT OF INFORMATION

I hereby authorize the Averroes high School Directors to provide routine health care, administer medications as ordered by a physician, obtain emergency medical treatment including radiology and laboratory studies, and arrangement of transportation for same. I agree to the release of any records necessary for medical treatment or insurance purposes. I consent to allow the physician selected by Averroes high school Directors to secure and administer treatment, including hospitalization for the minor named above.

Parent Signature

Print Name

I understand these risks and release Averroes High School, and the directors, trustees, officers, volunteers and employees of Averroes High School, from all liability for damages or injuries resulting from activity, negligence or defects in the preparation, instruction, or equipment.

Averroes High School is not responsible for lost, stolen, or damaged personal articles.

I individually and corporately agree to hold harmless, Averroes High School, its volunteers, agents, employees and officers irrespective of any negligent act or omission by Averroes High School and/or those individuals arising from or related in any way to this Averroes High School Summer Camp Program.

Parent Signature

Print Name

7. PAYMENT INFORMATION

Number of camp weeks

$400 per child

Type of Payment

Check submitted on first day of camp (Made payable to Averroes High School)Send me paypal information

Signature of Parent or Legal Guardian

Date