Waverly 2016 Summer Art Camp Registration
Monsters, Myths & Fantasy June 27 – July 22
*Please fil out one form per child
Student's Name
Male / Female
Birthdate
Age
Parent/ Guardian name
Parent/ Guardian relationship
Home address
City
Grade next fall
Zip
Parent/Guardian #1
Parent/Guardian #2
Home Phone:
Home Phone:
Cell Phone:
Cell Phone:
Emergency Contact:
Medical history/ or allergy:
Home Phone:
Cell Phone:
Is there a particular friend you would like to be with? If yes, what is his/her name?
Number the electives in order of preference, with 1 being your top choice - please number all electives.
Rising K - 2nd Grades
Music
Rising 3rd - 4th Grades
Music
Rising 5th - 7th Grades
Music and Soundscape
Performing Arts (1st–2nd only)
Performing Arts
Performing Arts
Games and Numbers
Stop Motion Animation
Stop Motion Animation
Story Hour
Digital Game Design
Digital Game Design
Board Game Design
Robotics
Sports
Board Game Design
Graphic Novel
Graphic Novel
Puppets and Costumes
Sports
Cool Chemistry
Puppets and Costumes
In addition to two Electives,
all K-2nd Grade campers will
have Art, Installation and Water
Magic classes
In addition to Electives, all 3rd – 7th Grade campers will have
Art and Installation classes
TUITION FEE ($100.00 NON-REFUNDABLE deposit is due at time of registration Remaining balance will be collected
on or before 6/1/2016. Please make checks payable to The Waverly School (67 W. Bellevue Dr. Pasadena, CA 91105)
______ $1,000 (Full 4-week session)
______ 5% Sibling discount ($50)
______ $35 field trip & T-shirt
(All campers)
______ $800 (3 weeks)
______ $35 field trip & T-shirt
(All campers)
Extended Care:
# of Days _______ at $10 per day =
$_____ Total Extended Care
$_________ Total Fee
I understand enrollment is based on first come first serve basis. I allow Waverly
& CW to contact 911 in the event of an emergency and I cannot be reached. I
authorize my child/ren to be treated by the first available licensed physician,
dentist, or surgeon, at the first available medical facility or hospital. I understand
that I am responsible for the medical fees of the above minor/s should s/he
require emergency medical treatment while attending summer camp or during
summer camp activities. I hereby agree that neither Waverly, CW, nor their
individual staff or volunteers shall be liable or responsible for any injuries that
may occur to the student at any time or any place during the summer camp
except those caused by willful malfeasance. 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 has a$50.00 nonrefundable fee. Participant cancellations made prior to two weeks before the
start of camp will result in a refund minus the $50 non-refundable fee. No
refunds will be honored once camp begins. I understand there are no cash
refunds if my child is absent due to illness, early withdrawal, or is removed from
camp due to behavior or discipline problems. Waverly & CW reserve the rights
to substitute camp activities as necessary. I allow my child to participate in
promotional pictures 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 ________________
Please complete this form (one for each child) and return it before or on the first day of camp.
PART I. PARENT/ GUARDIAN AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
I, _______________________________, the parent/ guardian of _____________________________ give my
(Parent’s name)
(Student’s name)
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)