GEERing Up! UBC Engineering & Science for Kids
Office Use Only
1100-2332 Main Mall, Vancouver V6T 1Z4
(ph) 604.822.2858 (fx) 604.822.2021
(email) [email protected]
(web) www.geeringup.apsc.ubc.ca
Processed
Paid
Confirmed
Summer Camp Registration 2012
IMPORTANT: ALL SECTIONS MUST BE FILLED IN TO COMPLETE REGISTRATION!
CAMPER INFORMATION
Participant’s Name:
Date of Birth:
First Name
Sex:
Female
Male
Grade (as of Fall 2012):
Returning Camper:
/
dd
Last Name
Yes
/
mm
yyyy
No
Does the participant identify as Aboriginal?
Yes
No
CAMP SELECTION
Please circle the desired camp
July 3 - 6
Explorers
(Gr 2-3)
$152
Imagineers
(Gr 4-5)
$152
Tech Inventors
(Gr 6-7)
$160
Explorers
(Gr 2-3)
$190
Explorers
(Gr 2-3)
$190
Girls Only!
Explorers
(Gr 2-3)
$190
Explorers
(Gr 2-3)
$190
Imagineers
(Gr 4-5)
$190
Imagineers
(Gr 4-5)
$190
Girls Only!
Imagineers
(Gr 4-5)
$190
Imagineers
(Gr 4-5)
$190
Tech Inventors
(Gr 6-7)
$200
Tech Inventors
(Gr 6-7)
$200
Girls Only!
Tech Inventors
(Gr 6-7)
$200
Tech Inventors
(Gr 6-7)
$200
August 13 - 17
Explorers
(Gr 2-3)
$190
Imagineers
(Gr 4-5)
$190
Tech Inventors
(Gr 6-7)
$200
August 20 - 24
Explorers
(Gr 2-3)
$190
Imagineers
(Gr 4-5)
$190
Tech Inventors
(Gr 6-7)
$200
July 9 - 13
July 16 - 20
July 23 - 27
July 30 –
August 3
Tech Innovators
(Gr 8-10)
$176
Tech Innovators
(Gr 8-10)
$220
Tech Innovators
(Gr 8-10)
$220
Tech Innovators
(Gr 8-10)
$220
CONTACT INFORMATION
Mailing Address:
City:
Province:
Postal Code:
Email:
Parent/Guardian Information
Name:
Phone: (
)
-
(
Home
Name:
Phone: (
)
-
(
Cell
)
-
(
Home
)
-
(
Cell
Emergency Contact (Family, friend, etc.)
Name:
Phone: (
)
-
(
Home
)
-
)
-
)
-
Work
Work
)
-
Cell
(
Work
ADDITIONAL INFORMATION (optional)
Please provide any additional information that will make the participant's time at GEERing Up! a
success. Note: Fields can be left empty if not applicable.
Health/Behavioural Considerations:
Allergies:
Does the participant have an Epi-Pen?
Yes
No
Medication:
Will the participant be taking medication during the camp day?
Yes
No
AGREEMENTS
Participant is authorized to leave GEERing Up! camps (select one):
On his/her own
With the people listed below
With the people listed below, only after Government-Issued ID has been checked
Authorized Release Persons List:
Unsupervised Lunch: (Only for participants entering Grades 8-10)
I give permission for the participant to have an unsupervised lunch. The participant will be able
to leave GEERing Up! camp for his/her lunch break without an instructor. The participant will be
responsible for his/her own actions on the UBC campus at these times.
If these actions are found inappropriate, I understand that the participant may be removed from
GEERing Up! camp without monetary reimbursement. I also understand that the ability to leave
camp at lunch is a privilege, and GEERing Up! instructors may suspend this privilege for
behaviour problems at their discretion.
Yes, I give permission
No, I do not give permission
Photo Permission:
I, hereby authorize GEERing Up! of the University of British Columbia and Actua, the National
organization to which GEERing Up! is a member, to photograph, audio record, video record,
podcast and/or webcast the participant (digitally or otherwise) without charge; and to allow
GEERing Up! and Actua to copy, modify and distribute in print and online, those images that
include the participant in whatever appropriate way either GEERing Up! and/or Actua sees fit
without having to seek further approval. No names will be used in association with any images
or recordings.
Yes, I give permission
No, I do not give permission
May GEERing Up! contact you about 2013 summer camps?
Yes
No
Longitudinal Study:
I, hereby authorize GEERing Up! to record the participant’s answers to an attitudinal survey and
track his/her progress throughout his/her time at GEERing Up!. Participation in this study will not
pose greater risk than those experienced in daily life. No names will be used in the publication
of the results.
Yes, I give permission
No, I do not give permission
Consent:
I consent and assume all risks and hazards of, and incidental to, the participation of the above
named child in the activities of GEERing Up! and agree to indemnify Actua and its sponsors, the
University of British Columbia and its officers, board of governors, servants, and agents
nominated or appointed by or on its behalf, and Actua and its supporters from and against all
loss from any claim hereafter made against it, them, or any of them by or on behalf of the said
child, and arising directly or indirectly from such participation.
I have read and understand the terms and conditions of the Internet Use Policy. I understand
that the University of British Columbia computer access is designed for educational purposes
only. GEERing Up! has taken precautions to restrict access to controversial materials and I will
not hold them responsible for materials acquired from the network. I understand that if the
above mentioned camper fails to comply with the terms and conditions of the Internet Use
Policy, s/he may be removed from GEERing Up! camp without monetary reimbursement.
I have read and understand the terms and conditions of the Appropriate Behaviour Agreement. I
understand that this policy is for the safety of my child, named above, and all children attending
GEERing Up! camp. I understand that if the above mentioned camper fails to comply with the
terms and conditions of the Appropriate Behaviour Agreement, s/he may be removed from
GEERing Up! camp without monetary reimbursement. My child, named above, and I have read
the Appropriate Behaviour Agreement, and agree that he/she will follow the GEERing Up!
Appropriate Behaviour Agreement while at camp.
I give permission for any GEERing Up! staff member to administer first aid treatment to the
above named child. I understand that every GEERing Up! staff member has been trained in
emergency first aid and will only provide care as needed.
Yes, I agree
I am the legal parent or guardian of _______________________________ (participant’s name).
The information in this application is correct and accurate.
________________________________
________________________________
Signed by Parent/Guardian
Date
FEE CALCULATION
Item
Camp Fee
Before Care (optional)
8:15 to 9:00am each day
After Care (optional)
3:00 to 4:00pm each day
Lunch Program (optional)
Note: Friday Pizza Lunch is free for all participants
Vegetarian Option
Donation to Bursary Fund
Please write in the amount if you wish to donate.
Tax receipts are available for donations greater than $25.00.
*
Cost
See page 1
$15.00
Subtotal
$
$
$20.00
$
$32.00
$
$
$
Total on
$
Cheque *
Our family cannot afford the Camp Fee. Our completed bursary application form is enclosed.
CHECKLIST
Have you completed all sections of the Registration Form?
Written a cheque payable to GEERing Up! UBC Engineering & Science for Kids for the amount
above?
Mail the completed registration form and cheque to:
GEERing Up! UBC Engineering & Science for Kids
1120E – 2332 Main Mall
Vancouver BC V6T 1Z4
Faxed or emailed registrations WILL NOT be accepted as we require payment (or a completed
bursary application form) with all camp registrations.
REGISTRATION POLICIES
Cancelation:
If you cancel more than two weeks prior to the first day of camp, GEERing Up! will refund camp
registration less a $50 reservation and processing fee. If you cancel less than two weeks prior to the
first day of camp, GEERing Up! will refund 50% of the registration fee. Cancellations after 4:00 pm
on the Friday before camp begins will receive no refund of registration fees, as it is at that point too
late to offer the spot to a wait-listed camper.
Registration changes:
Transfers (between camp weeks) are permitted, subject to program availability. Registration in the
Lunch Program cannot be changed less than two weeks prior to the first day of camp. Registration in
Before/After Care can be changed on the day-of.
Money (less than $50.00) owed by GEERing Up! (due to registration changes) will be issued in cash
to minimize the transaction fees.