Summer Science Youth Camp 2014
Complete this form for your child to be registered for Summer Science Youth Camp. Registration is not complete until payment is received. Upon completion of this form you will receive an email. Print the email form and submit with your payment. You will receive a confirmation post card when we receive the paper form and payment.
  • Emergency Contacts/Doctor and Insurance Information

    Please list two people we may contact in case of an emergency.
  • - -
  • - -
  • - -
  • - -
  • - -
  • Program Expectations/Releases:

    Children are expected to be courteous to one another and all staff members. Disruptive behavior will not be tolerated. Behavioral problems will be brought to the attention of the parent. I/we, the undersigned individually and as parent(s) of this minor; ask that he/she be admitted to participate in a program sponsored by Saint Francis University.

    I/we do hereby agree to release, discharge, and hold harmless Saint Francis University, its officers, agents, and employees of and from all causes, liabilities, damages, claims, or demands whatsoever on account of any injury or accident involving the said minor arising out of the minor's attendance in the Summer Science Youth Camps, or in the course of activities held in connection with a program offered by Saint Francis University.

    By signing below I/we authorize Saint Francis University personnel to photograph, videotape, and/or audiotape my/our child in promotion of Saint Francis University programs.

    Medical Treatment Authorization: I hereby authorize the staff of the hospital my child may be taken to provide care that includes routine diagnostic procedures (i.e., x-rays, blood, and urine tests) and medical treatment necessary to my minor child. I understand that the consent and authorization herein granted does not include major surgical procedures and is valid only during Summer Science Youth Camps. Saint Francis University will not dispense over-the-counter (OTC) or prescription medication to participants. In the event that an illness or injury would require more extensive evaluation, I understand that every reasonable attempt will be made to contact me. However, in the event of an emergency, the hospital my child is taken to is to perform any necessary emergency treatment.

    I will drop my child off and pick my child up according to the instructions provided on the confirmation postcard I will receive in the mail.
  • / /
Powered byEMF Online HTML Form
Report Abuse