Waverly 2017 Summer Art Camp Registration
Land of the Future June 19 – July 14, 2017
*Please fill out one form per child
Camper’s Name
Address
Male / Female
Birthdate
Age
Parent/ Guardian 1
Phone:
Email:
Emergency Contact:
Phone:
Is there a particular friend you would like to be with?
If yes, what is his/her name?
Grade next fall
Parent/ Guardian 2
Phone:
Email:
Medical history/ or allergy:
T-Shirt Size:
Youth XS___
S___
M___ L___ XL___
Number the electives in order of preference, with 1 being your top choice - please number all electives.
Rising K - 2nd Grades
Rising 3rd - 4th Grades
Rising 5th - 7th Grades
Soundscape Design
Soundscape Design
Performing Arts (1 – 2 only)
Drama
Drama
Games and Patterns
Stop Motion Animation
Stop Motion Animation
Story Hour
Digital Game Design
Digital Game Design
Mechanical Toys
Mechanical Toys
Sports
Sports
Graphic Novel
Graphic Novel
Giant Puppets
Giant Puppets
Music
st
nd
In addition to two Electives,
all K-2nd Grade campers will have
Art, Installation and Water Magic
classes
Mad Science
Robotics
rd
th
In addition to Electives, all 3 – 7 Grade campers will have Art and
Installation classes
Tuition Fee
______ $1,150 (full 4 week session)
______ Sibling Discount ($50)
______ $900 (3 weeks)
Extended Care
_________ Days x $10 per day =
$________ Total Extended Care
_________ To Be Determined
(I will need extended care, but I don’t know for
how many/ which days)
Total Fee:
$_______________
I understand enrollment is based on first come first served basis. I must
disclose any special needs or allergies my child may have and agree to
provide arrangements as required by Waverly & CW. I understand
cancellation of any session does not include refund of the $100
registration deposit. No refunds will be honored once camp begins. I
understand there are no refunds if my child is absent due to illness, partial
week attendance, or is removed from camp due to behavior or discipline
problems. Waverly & CW reserve the right to substitute camp activities as
necessary. I allow my child to participate in promotional pictures or other
media from the camp. I certify that I have legal authority to sign this
release waiver of liability, and sign it without coercion. I have read and
understood the Waverly & CW rules and policies.
Signature ________________________________
Date ___________
For Office Use
_____________ $100 Non-Refundable Deposit
Check # ______ CC _____ Cash ______
(remaining balance due 5/26/2017)
$____________ Paid in Full
Check # ______ CC _____ Cash ______
Medical Waiver Forms ________
Waverly 2017 Summer Art Camp Emergency/Medical/Field Trip Form
Land of the Future June 19 – July 14, 2017
Please complete this form (one for each child) and return it before the first day of camp.
PART I. PARENT/ GUARDIAN AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
I, _______________________________, the parent/ guardian of _____________________________
(Parent’s name)
(Student’s name)
give my authorization for the Waverly School and Creative World to seek medical assistance for my child
should the need arise. The Waverly School and Creative World has my permission to take my son/
daughter to a hospital and sign any authorization for emergency medical treatment. I understand that I am
responsible for all medical costs, and waiver any and all responsibility of the Waverly School and
Creative World and the school’s individual employees, contracted professionals, and volunteers for any
medical and/ or other costs associated with any of the Waverly School and Creative World function. I am
responsible to notify The Waverly School and Creative World if any of the information below changes.
PART II. MEDICAL CONDITIONS AND INFORMATION
IMPORTANT: please advise us of medical accommodations your child needs that might require specific
attention or precautions.
Medical conditions
____________________________________________________________________________________
Medications your child is currently taking
____________________________________________________________________________________
List any known allergies your child has
____________________________________________________________________________________
Name if family health insurance company
____________________________________________________________________________________
Health insurance policy number
____________________________________________________________________________________
Family doctor’s name, contact, and address
_____________________________________________________________________________________
PART III. STUDENT AND PARENT FIELD TRIP AGREEMENT
Student and parent/ guardian agree to:
1. Represent The Waverly School and Creative World. The student agrees to behave with the highest
degree of professional behavior and to comply with all The Waverly School and Creative World policies
for the duration of all activities.
2. Acknowledge that each student is assigned to an adult chaperone and a specific group for the duration
of the field trip. It is critical to inform adult chaperones of student whereabouts and/or emergency
situations.
3. Follow the consent to individual and group instructions and/or rules for the duration of the field trip.
4. Release The Waverly School and Creative World individual staff from all liability.
5. Accept the consequences of improper behavior. The Waverly School and Creative World has the right
to expel students who participate in illegal activities such as, but not limited to theft, or vandalism.
Parents will assume all costs for damages to rooms, buses, facilities, return transportation home, etc.
Any advance payments will be forfeited.
____________________________________
(Signature)
_____________
(Date)