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.
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 #
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