ANSATECHNOLOGY AND ADVENTURE
SUMMER CAMP @West Philly High School
Philadelphia, PA 19139
267-581-8888
APPLICATION FORM
ORIENTATION DATES AND TIMES TO BE ANNOUNCED!
2017 Whiz Kidz Summer Camp Dates: July 3rd to August 11th - Mon. through Fri. Time: 8:30 a.m. – 3:00
p.m.Before Care starts at 7:30am After Care is until 6:00pm.
Registration is required. Mail or bring Registration form with payment to:
ANSA Whiz Kidz @ Lea School between 3pm and 6pm Mon – Fri Call 267-581-8888 for entry to building.
Camp Fees: We Accept CCIS Scholarships available on 1st come 1st serve basis rate: Free - $66/wk
Grade
Full Time Part Time.
PreK
K - 3rd
4th - 15yrs
$38/day
$32.40/day
$28/day
$31/day
$28/day
$28/day
If possible, please complete application online at www.asacomputertraining.com. Email completed
documents to [email protected]. Fax to 1-866-834-8236. Scholarship slots are allocated on a 1st come, 1st
serve basis to those who qualify. Complete the Means Test form attached to application. Medical forms are
required within 5 days of start date.
Please Print
DATE:
CHILD'S
FULL
NAME:
Date of
Birth/Age:
Male____ Female___
Grade in June 2017?
T-Shirt Size: (Please circle)
Child: S
Adult: S
M
L
Street Address:
City:
M
L
Apt. #.
State:
Zip
Work:
Cell:
Work:
Cell:
Print -- Mother's / Guardian's Name
Phone #:
Home:
Print -- Father's / Guardian's Name
Phone #:
Signature:
Home:
(
) Parent
(
) Guardian (
) Other_______
Camp Registration Fee: $20 per child
Breakfast, Lunch, and Snack included in the cost of the weekly fee. Breakfast begins at 8:00am
PLEASE NOTE: Registration, Cancellation and Refund Policies: Registration, Camp and Weekly rates are
non-refundable. All Registration fees must be accompanied with this registration form, signed by the parent(s) or
guardian, and includes 1 full weekly payment to confirm registration. Phone in reservations will require faxed form
and credit card payment. CCIS pre-approval is required. DHS grants must have an approval letter from social worker.
Weekly Fee Amount: ______________ Registration Fee: due with Application Paid on: ____________________________ Amount Paid:
Before Care? Y or N
After Care? Y or N_____________
Condition of Enrollment Form
Liability: I (we) understand that personal property of the camper is the sole responsibility of the camper and
that ANSA Educational Services/ASA Technology Academy/Whiz Kidz and/or Darlene’s Darlings will not be
held liable for loss or damage of these personal articles. Further I (we) release ANSA Educational
Services/ASA Technology Academy/Whiz Kidz and/or Darlene’s Darlings, its agents and employees from any
and all claims for personal injuries or other damages. I understand that in the event of an injury to my child, a
licensed physician or nurse may determine that my child may need medical or surgical services. I hereby
authorize, appoint and empower ANSA Educational Services/ASA Technology Academy/Whiz Kidz and/or
Darlene’s Darlings to act as my agent for the purpose of authorizing such physician or nurse to provide such
services, it being my desire that my child be provided with such services at my expense as soon as reasonably
possible after the need arises.
I also certify that my child has no physical or mental condition or impairment that would preclude him/her from
participating in the activities of the Camp, and I give my permission for my child to participate in those
activities.
I am age 18 or older, and I am not under any legal disabilities that prevent me from being legally bound by this
document. I agree that this document and any dispute arising from or involving this document, shall be
governed and construed in accord with the laws of the State of Pennsylvania.
Permission to Participate: I (we) understand that the camper names below may take part in all sports and
activities unless I (we) want to restrict such activities. To the best of my (our) knowledge my (our) child has no
emotional or physical problems that would prevent their attendance at this time.
I (WE) HAVE READ AND ACCEPT ALL OF THE CONDITIONS OF ENROLLMENT AS STATED
ABOVE:
Parent/Guardian Signature_______________________________________
Date Signed_______________________________________
Name of Camper_______________________________________
Parent/Guardian Signature_______________________________________
Date Signed_______________________________________
Name of Camper_______________________________________
Medical Information Form – Please attach most recent physical/shot records
CODE WORD FOR EMERGENCY PICKUP:_________________________________________
Use your favorite color, pet's name, name of elementary school etc...