Summer Camp Registration Form

Transcription

1 City of San Mateo Parks & Recreation Department Summer Camp Registration Form 1 Account 2 Additional Main Contact Name & Information Parent/Legal Guardian Name Mr. Ms. Mrs. first and last name Date of Birth (must be 18yrs or older) month / day / year Main Phone Number If you have been a past participant in our programs, skip to Part 3. Contact Information Residence Address no. and street city and zip + 4 code address Phone Numbers home (area code + number) cell (area code + number) work (area code + number) Emergency Contact Name first and last name relationship Phone Numbers home / cell (area code + number) work (area code + number) Camp Modification Request: We encourage and support the participation of individuals with all ability levels in programs and services. This includes those with disabilities, and in need of reasonable program modifications in order to participate. Please complete the statement: I am requesting a reasonable program modification for the class/program(s) listed on this registration form. Yes No Participants Name 4 5 Complete 6 Sign Complete Summer Camp Registration Forms Summer Camp Fees Total $ Withdrawal Reminder: You may withdraw from your registered camp and receive 100% of paid fees through Monday at 11:59pm 7 calendar days prior to your camp beginning. Payment Information By checking yes you authorize the City of San Mateo to automatically charge the credit card listed for the entire balance. Check Cash Other (payable to City of San Mateo) (Circle one) credit card payment authorization exp. mo/yr 3 digit security code authorized signature (as shown on credit card) and Date billing zip code A signature is required by a parent or legal guardian. WAIVER OF LIABILITY & PHOTO RELEASE: In consideration of participation in the City of San Mateo recreation program described above (the Activity ), I the undersigned for myself and/or as the parent/guardian of the Minor named above, agree to indemnify and hold the City of San Mateo, it s elected and appointed officials, employees, and agents (the City ) harmless and hereby waive, release and discharge any and all claims for damage, for death, personal injury, bodily injury or property damage which I and/or the Minor may have or which hereinafter may accrue to me and/or the Minor against the City from and against any liability arising out of or connected in any way with my and/or the Minor s participation in this Activity, even though that liability may arise out of negligence or carelessness on the part of the person or entities mentioned above. I understand that accidents and injuries can arise from participation in this class or activity; knowing the risks, nevertheless, I hereby agree to assume those risks on behalf of me and/or the above named Minor and to release and to hold harmless all of the persons or entities mentioned above whom (though negligence or carelessness) might otherwise be liable to me and/or the above named Minor (or my/our heirs or assignees) for damages. It is further understood and agreed that this waiver, release and assumption or risks has been freely entered into and is to be binding on my/our heirs and assigns. I have read and agree to the registration and program policies. Further, I agree to allow use of my image and/or that of the named minor, which may be captured through video, photo, digital camera or other media, for City of San Mateo promotional materials and publications. By my signature below, I acknowledge that I have read this document and understand its contents. Check the appropriate space(es) and sign: Participant (over 18) Signature: Date: 3 Camper Info Print Name: self parent guardian First and last name Birthday: Month / day / year boy girl 25

2 NEW! Electronic Emergency Forms with epact The City of San Mateo Parks and Recreation Department is excited to announce we are now using epact Network to replace our paper emergency forms! WHAT IS IT? epact is a secure online network we will use to collect important and sensitive emergency information regarding our campers. epact will also provide us with a way to communicate with you quickly and effectively in the event of injury, illness or a larger emergency event. HOW DOES IT WORK? After you register for camp, you ll receive an invite. You create a free account, or log-in if you already have an existing epact account. Enter or update the required information and share it so that program staff have access. WHY epact? epact replaces paper forms! You only have to complete it one time. Updates can easily be made from home. Staff always have access to records with epact's mobile app, and the system maintains the same levels of security as online banking. 26 CAMP HOTLINE 522-SUMM or

3 2019 Mini Camps CAMPER NAME WEEKS 1 & 7 Week 1: June Activity Name Barcode List Fee Your Fee Week 7: August 5-9 Activity Name Barcode List Fee Your Fee Summer Kids Club FD Camp Hay Day - Beres F-A1 $247 Summer Kids Club FD Camp Hay Day - Beres F-G1 $247 Camp Hay Day - King F-A4 $247 Camp Hay Day - King F-G4 $247 Summer Kids Club AM Camp Hay Day - Beres A-A2 $150 Summer Kids Club AM Camp Hay Day - Beres A-G2 $150 Camp Hay Day - King A-A5 $150 Camp Hay Day - King A-G5 $150 Summer Kids Club PM Camp Hay Day - Beres P-A3 $150 Summer Kids Club PM Camp Hay Day - Beres P-G3 $150 Camp Hay Day - King P-A6 $150 Camp Hay Day - King P-G6 $150 S.K.C. Local Trip Rinconada Park & Pool, PA - Beres A4 $32 S.K.C. Local Trip Pump it Up, Belmont - Beres G4 $32 Rinconada Park & Pool, PA - King A6 $32 Pump it Up, Belmont - King G6 $32 S.K.C. Adventure Trip Golfland, San Jose - Beres A5 $51 S.K.C. Adventure Trip Zoo, San Francisco - Beres G5 $51 Golfland, San Jose - King A7 $51 Zoo, San Francisco - King G7 $51 AM Specialty Camp Kidz Love Soccer - Beres $172 AM Specialty Camp Culinary Mischief - Beres A1 $272 Green Screen Logo Flix - King A1 $280 Junior Chef Stars - Beres A1 $325 Rebound Basketball - Beres A1 $182 Kidz Love Soccer - Beres $172 Society Skateboarding - Beres A1 $220 Mad Science - King A1 $279 Skyhawks: Multi Sport-Beres A1 $242 PM Specialty Camp IncrediFlix: Animation Flix - King A1 $280 PM Specialty Camp Junior Chef Stars - Beres A1 $325 Specialty Combo Camp Lego and Animation Flix B1 $495 Mad Science - King A1 $279 * Please submit with Registration Form on page

4 2019 Summer Camps CAMPER NAME WEEKS 2-6 Week 2: July 1-3 Activity Name Barcode List Fee Your Fee Week 5: July Activity Name Barcode List Fee Your Fee Summer Kids Club FD Camp Hay Day F-B1 $148 Summer Kids Club FD Camp Hay Day F-E1 $247 Summer Kids Club AM Camp Hay Day A-B2 $90 Summer Kids Club AM Camp Hay Day A-E2 $150 Summer Kids Club PM Camp Hay Day P-B3 $90 Summer Kids Club PM Camp Hay Day P-E3 $150 S.K.C. Local Trip Century 12 & Central Park, SM B4 $32 S.K.C. Local Trip Laser Quest, San Carlos E4 $32 S.K.C. Adventure Trip Tech Museum, San Jose E5 $51 AM Specialty Camp Kids Carpentry A1 $198 AM Specialty Camp Fizz-ical Phen. & Che-Mystery A1 $279 Hoop it Up A1 $144 Kids Carpentry A2 $297 Skyhawks: Mini Hawk Sports A2 $154 Musical Theater Camp A1 $272 STEM-ulating Science A1 $180 Rallyball Tennis B1 $300 Rebound Basketball C1 $182 Society Skateboarding B1 $220 PM Specialty Camp Dragonfly Design Leather A1 $355 PM Specialty Camp Kids Carpentry B1 $195 Kids Carpentry A1 $297 Musical Theater Camp B1 $272 Fizz-ical Phen. & Che-Mystery B1 $279 Week 3: July 8-12 Activity Name Barcode List Fee Your Fee Week 6: July 29 - Aug. 2 Activity Name Barcode List Fee Your Fee Summer Kids Club FD Camp Hay Day F-C1 $247 Summer Kids Club FD Camp Hay Day F-F1 $247 Summer Kids Club AM Camp Hay Day A-C2 $150 Summer Kids Club AM Camp Hay Day A-F2 $150 Summer Kids Club PM Camp Hay Day P-C3 $150 Summer Kids Club PM Camp Hay Day P-F3 $150 S.K.C. Local Trip Bowling, Bel Mateo Bowl C4 $32 S.K.C. Local Trip Rockin Jump, San Carlos F4 $32 S.K.C. Adventure Trip Aqua Adventure, Fremont C5 $51 S.K.C. Adventure Trip Academy of Sciences, SF F5 $51 AM Specialty Camp Society Skateboarding A2 $220 AM Specialty Camp Action Movie Flix A1 $280 Fantasy Forest A1 $272 Rebound Basketball D1 $182 Reactions in Action A1 $279 Skateboarding Camp B2 $220 Techsplosion: YouTube Stars A1 $275 Yoga and Art B1 $270 PM Specialty Camp Jet Cadets A1 $279 PM Specialty Camp Dragonfly Design A1 $355 Clay-Hands on Art A1 $210 Minecraft Movie Flix A1 $280 Skyhawks: Flag Football A1 $242 Summer Fiesta A1 $272 Skyhawks: Cheer Camp A1 $242 Specialty Combo Camp Action and Minecraft Flix B1 $495 Video Game Design with Minecraft A1 $275 Week 4: July Activity Name Barcode List Fee Your Fee Summer Kids Club FD Camp Hay Day F-D1 $247 Summer Kids Club AM Camp Hay Day A-D2 $150 Summer Kids Club PM Camp Hay Day P-D3 $150 S.K.C. Local Trip Ice Skating, San Mateo D4 $32 S.K.C. Adventure Trip Exploratorium, San Francisco D5 $51 AM Specialty Camp Yoga and Art A1 $270 Rebound Basketball B1 $182 YouTube Stars! A1 $275 PM Specialty Camp Dragonfly Design: Art and Jewelry A1 $355 Stop Motion Minecraft Animation A1 $248 Cartoon Workshop A1 $272 Rallyball Tennis A1 $300 * Please submit with Registration Form on page CAMP HOTLINE 522-SUMM or

5 CAMPER NAME * Please submit with Registration Form on page 25 SUMMER 2019 Other Great Camps Week 1: 6/24-6/28 Week 2: 7/1-7/5 Week 3: 7/8-7/12 Week 4: 7/15-7/19 Week 5: 7/22-7/26 Week 6: 7/29-8/2 Week 7: 8/5-8/9 Week 8: 8/13-8/17 PRESCHOOL Ages Barcode Fee Barcode Fee Barcode Fee Barcode Fee Barcode Fee Barcode Fee Barcode Fee Barcode Fee Myriad Performing Arts A1 $ B1 $ C1 $ D1 $230 Pre Kamp - Shoreview PreK A1 $ B1 $ C1 $ D1 $ E1 $ F1 $143 Pre Kamp - Lakeshore PreK A2 $ B2 $ C2 $ D2 $ E2 $ F2 $143 Pre Kamp - Beresford PreK B3 $ C3 $ D3 $ E3 $ F3 $143 SCHOOL AGE Ages Barcode Fee Barcode Fee Barcode Fee Barcode Fee Barcode Fee Barcode Fee Barcode Fee Barcode Fee Fencing: Full Day 7-12 yrs C1 $ D1 $ E1 $ F1 $ G1 $ H1 $400 Fencing: Half Day AM 7-12 yrs C2 $ D2 $ E2 $ F2 $ G2 $ H2 $225 Fencing: Half Day PM 7-12 yrs C3 $ D3 $ E3 $ F3 $ G3 $ H3 $225 CA: Advanced Math 8-11 yrs A1 $ B1 $ C1 $340 CA: Adv. English: Word Choice & Fluency 8-11 yrs A1 $340 CA: Adv. Math & Public Speaking 8-11 yrs A1 $615 CA: Adv. Math & Adv. English 8-11 yrs B1 $615 CA: Adv. Math & Debate 8-11 yrs C1 $ CA:Debate/Critical Thinking: Mock Trial 8-11 yrs A1 $330 CA: Public Speaking: Creative Interpret yrs A1 $ B1 $ A1 $330 Create, Mix & Mingle: Half Day AM* 5-13 yrs C2 $ D2 $ E2 $ F2 $ G2 $ H2 $ I2 $ J2 $285 Create, Mix & Mingle: Half Day PM* 5-13 yrs C3 $ D3 $ E3 $ F3 $ G3 $ H3 $ I3 $ J3 $285 Create, Mix & Mingle: Full Day* 5-13 yrs C1 $ D1 $ E1 $ F1 $ G1 $ H1 $ I1 $ J1 $495 ETC Children s Musical: Disney s The Jungle Book 6-9 yrs A1 $840 ETC Children s Musical: Seussical 6-9 yrs B1 $960 ETC Youth Musical: Disney s The Lion King 9-14 yrs A1 $810 ETC Youth Musical: Junior Musical TBD 9-14 yrs B1 $910 Fashion Design: Half Day 8-17 yrs A2 $ B2 $ C2 $ D2 $ E2 $ F2 $ G2 $410 Fashion Design: Full Day 8-17 yrs A1 $ H1, H2, H3 $ B1 $ C1 $ D1 $ E1 $ F1 $ G1 $610 Horse-Back Riding 8-14 yrs A1 $ B1 $ C1 $ D1 $ E1 $ F1 $ G1 $450 Indoor Rock Climbing 5-13 yrs A1 $ B1 $ C1 $ D1 $ E1 $ F1 $ G1 $155

6 30 CAMP HOTLINE 522-SUMM or SUMMER 2019 Other Great Camps Week 1: 6/24-6/28 Week 2: 7/1-7/5 Week 3: 7/8-7/12 Week 4: 7/15-7/19 Week 5: 7/22-7/26 Week 6: 7/29-8/2 Week 7: 8/5-8/9 Week 8: 8/13-8/17 SCHOOL AGE, continued Ages Barcode Fee Barcode Fee Barcode Fee Barcode Fee Barcode Fee Barcode Fee Barcode Fee Barcode Fee Jr. Chef Stars- Cupcake Masters 7-12 yrs A1 $300 Jr. Chef Stars-Let Them Eat Cake 7-12 yrs A1 $300 Jr. Chef Stars-United States of Appetites 7-12 yrs A1 $300 Jr. Chef Stars-Baking Championshpi 7-12 yrs A1 $318 Jr. Chef Stars: Future Celebrity Chef 7-12 yrs A1 $300 Jr. Chef Stars: Junior Master Chef 7-12 yrs A1 $318 Mad Science: Wacky Robots & Widgets 7-12 yrs A1 $272 Mad Science: Young Inventors 7-12 yrs A1 $272 Myriad Performing Arts 5-7 yrs A1 $ B1 $ C1 $ D1 $ E1 $465 Neighborhood Summer Fun 6-10 yrs P-A2 $ P-A3 $ P-A4 $ P-A5 $ P-A6 $75 Pong Planet s Ping Pong 6-13 yrs A1 $ B1 $ C1 $ D1 $ E1 $ F1 $ G1 $365 Rallyball Tennis: NF Half Day 7-14 yrs A1 $ B1 $265 Rallyball Tennis: NF Full Day 7-14 yrs A2 $ B2 $ F3 $359 Rebound Basketball 5-11 yrs A1 $ B1 $ C1 $ D1 $155 Skyhawks- Multi Sport: NF Half Day 6-12 yrs A1 $ A1 $235 Skyhawks- Multi Sport: NF Full Day 6-12 yrs B1 $569 Skyhawks-Mini Hawk: NF Half Day 6-12 yrs A1 $217 Skyhawks-Mini Hawk: NF Full Day 4-7 yrs B1 $330 Techsplosion Minecraft Challenge 7-12 yrs A1 $300 Ultimate Frisbee Camp 8-14 yrs A1 $305 ViBO: Camp Allegro 6 yrs B1 $ C1 $820 Youth Sailing 8-13 yrs A1 $ B1 $ C1 $ D1 $ E1 $ F1 $ G1 $475 * Classes start as early as 6/ A1, A2, A3, B1, B2, B3 Extra week 8/19-8/23 Use J1-3 TEEN Ages Barcode Fee Barcode Fee Barcode Fee Barcode Fee Barcode Fee Barcode Fee Barcode Fee Barcode Fee S.T.@.K (Summer Time at King) yrs A1 $ A2 $ A3 $ A4 $ A5 $ A6 $ A7 $47 X-treme Summer Days (XSD) yrs A1 $ A2 $ A3 $ A4 $ A5 $ A6 $ A7 Leaders in Training (LIT) yrs A1 $ A2 $ A3 $ A4 $130 CAMPER NAME * Please submit with Registration Form on page 27. Myriad s Film Scoring yrs A1 $ B1 $455