Art and Learning Center Summer Camp

Art and Learning Center Summer Arts Camp Registration Form

The Art and Learning Center offers four one-week day camps for children ages 6-12. Everyday campers will participate in three specialties. Specialties will change each week..

Hours:	9:00-3:00 (After Care 3:00-5:00)
Ages:	6 – 12 years old (as of July 9, 2007)
Rates:	$150 per week After Care - $40 per week

Session I: 7/7/2008 - 7/11/2008
Under the Sea

Session II: 7/14/2008 - 7/18/2008
Cultures of the World

Session III: 7/21/2008 - 7/25/2008
Outer Space

Session IV: 7/28/2008 - 8/1/2008
Into the Jungle

^* Indicates Required Field

Parent/Guardian Information

^*First Name:

^*Last Name:

Bill Payer First Name:

Bill Payer Last Name:

(if different)

^*Address:

^*City:

^*State: ^*Zip:

^*Phone (Home):

Phone (Work):

^*Email:

Camper Information

^*First Name:

^*Last Name:

^*Birth Date:

^*Age Group:
(As of July 7, 2008)

6-7 8-9 10-12

^*Grade Level Entering (Fall 2008):

Session	Aftercare	Session Status
Session I - 7/7/2008-7/11/2008	Yes	Age Group:6-7 Spots Remaining: FULL Age Group:8-9 Spots Remaining: 4 Age Group:10-12 Spots Remaining: 5
Session II - 7/14/2008-7/18/2008	Yes	Age Group:6-7 Spots Remaining: FULL Age Group:8-9 Spots Remaining: FULL Age Group:10-12 Spots Remaining: 3
Session III - 7/21/2008-7/25/2008	Yes	Age Group:6-7 Spots Remaining: FULL Age Group:8-9 Spots Remaining: 3 Age Group:10-12 Spots Remaining: 4
Session IV - 7/28/2008-8/1/2008	Yes	Age Group:6-7 Spots Remaining: FULL Age Group:8-9 Spots Remaining: 2 Age Group:10-12 Spots Remaining: FULL

Total Price:

Waiver claim: The University assumes no liability for injury or damage from participation in this program. I understand that my child's participation is contingent upon my signature on the Permission and Release form to be sent later. I understand that there will be no refunds unless the Art and Learning Center (ALC) cancels the camp session.

^*I have read and agree to the Refund Policy and Waiver Claim.

PERMISSION & RELEASE

^*I give my permission for my child to participate in all University of Maryland Art and Learning Center Summer Arts Camp activities, including but not limited to walking tours of the campus.

^*In consideration of the University's willingness to accept my child into the Art and Learning Center Summer Arts Camp program and to provide the services and benefits of the camps, I hereby release and shall indemnify and hold harmless the University of Maryland, its officers agents and/or employees from any and all liability for any harm or injury arising either directly or indirectly from my child's participation in the Summer Arts Camp program.

^*Primary Emergency Contact:

^*Phone:

Email:

^*Secondary Emergency Contact:

^*Phone:

Email:

CAMPER HEALTH HISTORY

REQUIRED IMMUNIZATIONS
All campers must be current on all immunizations, unless they provide a written statement from either a licensed physician indicating that the immunization is medically contraindicated, or the parent or guardian indicating that they object to immunizations for religious reasons. Use the Maryland Department of Health and Mental Hygiene Immunization Certificate.
^*A. Date (month and year) of camper's last tetanus (or DTP) shot: /
^*B. Is camper currently enrolled in a Maryland school, public or private?
C. If (B) is no, furnish a record of immunizations for diphtheria, tetanus, pertussis, poliomyelitis, measles (rubeola), rubella (German measles), and mumps.
^*D. Is camper exempt from immunizations on medical or religious grounds?
E. If (D) is yes, provide signed copy of Maryland Department of Health and Medical Hygiene Immunization Certificate.

^*Physician's Name:

^*Phone:

^*Are there any special needs, medical conditions, or behavioral conditions that we need to be aware of to ensure that your child's camp experience is positive. Check any that apply and give more information.

Good general health	Seizure	Behavioral issue
Allergy (food, insect, drug, other)	Asthma	Significant mental health condition
Diabetes	Prescription medication	Other chronic health condition
Other medication

Explain:

^*Is your child under the care of a physician for a medical problem?

If yes, please explain:

^*Is your child taking any medication prescribed by a physician?

If yes, please list all medications
(including over-the-counter medications):

Other information we should be aware of:

^*I certify that there are no other conditions which might interfere with my child's participation in the Summer Arts Camp program or which might result in such participation being harmful to his/her health or well being.

^*In the event that a health emergency arises and I can not be contacted by telephone, I consent to and authorize treatment as it is deemed necessary by health care personnel selected by the University of Maryland.

^*I give my permission for such diagnostic and therapeutic procedures as may be deemed necessary for my child by the University of Maryland Health Center.

Minimum camper health information needed to comply with COMAR 10.16.06.08

PICKUP & DROP OFF

Please fill out the following information. Children will be sent home ONLY with their parents or legal guardians, or those listed on this form.

Adults designated for child pick up and drop off (please enter name and phone number):

PHOTO RELEASE

I hereby give my permission for my child to have his/her photograph taken by the staff of the Summer Arts Camp for the purposes of display or publication.