Summer Camp Registration Form

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 email 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 www.cityofsanmateo.org/summercamps 25

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 email 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 www.sanmateorec.org

2019 Mini Camps CAMPER NAME WEEKS 1 & 7 Week 1: June 24-28 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 320301F-A1 $247 Summer Kids Club FD Camp Hay Day - Beres 320301F-G1 $247 Camp Hay Day - King 320301F-A4 $247 Camp Hay Day - King 320301F-G4 $247 Summer Kids Club AM Camp Hay Day - Beres 320301A-A2 $150 Summer Kids Club AM Camp Hay Day - Beres 320301A-G2 $150 Camp Hay Day - King 320301A-A5 $150 Camp Hay Day - King 320301A-G5 $150 Summer Kids Club PM Camp Hay Day - Beres 320301P-A3 $150 Summer Kids Club PM Camp Hay Day - Beres 320301P-G3 $150 Camp Hay Day - King 320301P-A6 $150 Camp Hay Day - King 320301P-G6 $150 S.K.C. Local Trip Rinconada Park & Pool, PA - Beres 320306-A4 $32 S.K.C. Local Trip Pump it Up, Belmont - Beres 320306-G4 $32 Rinconada Park & Pool, PA - King 320306-A6 $32 Pump it Up, Belmont - King 320306-G6 $32 S.K.C. Adventure Trip Golfland, San Jose - Beres 320306-A5 $51 S.K.C. Adventure Trip Zoo, San Francisco - Beres 320306-G5 $51 Golfland, San Jose - King 320306-A7 $51 Zoo, San Francisco - King 320306-G7 $51 AM Specialty Camp Kidz Love Soccer - Beres 320564 $172 AM Specialty Camp Culinary Mischief - Beres 321042-A1 $272 Green Screen Logo Flix - King 321144-A1 $280 Junior Chef Stars - Beres 321193-A1 $325 Rebound Basketball - Beres 320548-A1 $182 Kidz Love Soccer - Beres 320564 $172 Society Skateboarding - Beres 320561-A1 $220 Mad Science - King 321160-A1 $279 Skyhawks: Multi Sport-Beres 320550-A1 $242 PM Specialty Camp IncrediFlix: Animation Flix - King 321144-A1 $280 PM Specialty Camp Junior Chef Stars - Beres 321150-A1 $325 Specialty Combo Camp Lego and Animation Flix 321141-B1 $495 Mad Science - King 321162-A1 $279 * Please submit with Registration Form on page 25. www.cityofsanmateo.org/summercamps 27

2019 Summer Camps CAMPER NAME WEEKS 2-6 Week 2: July 1-3 Activity Name Barcode List Fee Your Fee Week 5: July 23-27 Activity Name Barcode List Fee Your Fee Summer Kids Club FD Camp Hay Day 320301F-B1 $148 Summer Kids Club FD Camp Hay Day 320301F-E1 $247 Summer Kids Club AM Camp Hay Day 320301A-B2 $90 Summer Kids Club AM Camp Hay Day 320301A-E2 $150 Summer Kids Club PM Camp Hay Day 320301P-B3 $90 Summer Kids Club PM Camp Hay Day 320301P-E3 $150 S.K.C. Local Trip Century 12 & Central Park, SM 320306-B4 $32 S.K.C. Local Trip Laser Quest, San Carlos 320306-E4 $32 S.K.C. Adventure Trip Tech Museum, San Jose 320306-E5 $51 AM Specialty Camp Kids Carpentry 321046-A1 $198 AM Specialty Camp Fizz-ical Phen. & Che-Mystery 321161-A1 $279 Hoop it Up 320546-A1 $144 Kids Carpentry 321046-A2 $297 Skyhawks: Mini Hawk Sports 320555-A2 $154 Musical Theater Camp 320942-A1 $272 STEM-ulating Science 321194-A1 $180 Rallyball Tennis 320559-B1 $300 Rebound Basketball 320548-C1 $182 Society Skateboarding 320561-B1 $220 PM Specialty Camp Dragonfly Design Leather 321059-A1 $355 PM Specialty Camp Kids Carpentry 321046-B1 $195 Kids Carpentry 321046-A1 $297 Musical Theater Camp 320942-B1 $272 Fizz-ical Phen. & Che-Mystery 321161-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 320301F-C1 $247 Summer Kids Club FD Camp Hay Day 320301F-F1 $247 Summer Kids Club AM Camp Hay Day 320301A-C2 $150 Summer Kids Club AM Camp Hay Day 320301A-F2 $150 Summer Kids Club PM Camp Hay Day 320301P-C3 $150 Summer Kids Club PM Camp Hay Day 320301P-F3 $150 S.K.C. Local Trip Bowling, Bel Mateo Bowl 320306-C4 $32 S.K.C. Local Trip Rockin Jump, San Carlos 320306-F4 $32 S.K.C. Adventure Trip Aqua Adventure, Fremont 320306-C5 $51 S.K.C. Adventure Trip Academy of Sciences, SF 320306-F5 $51 AM Specialty Camp Society Skateboarding 320561-A2 $220 AM Specialty Camp Action Movie Flix 321143-A1 $280 Fantasy Forest 321056-A1 $272 Rebound Basketball 320548-D1 $182 Reactions in Action 321195-A1 $279 Skateboarding Camp 320561-B2 $220 Techsplosion: YouTube Stars 321187-A1 $275 Yoga and Art 321049-B1 $270 PM Specialty Camp Jet Cadets 321156-A1 $279 PM Specialty Camp Dragonfly Design 321054-A1 $355 Clay-Hands on Art 321048-A1 $210 Minecraft Movie Flix 321142-A1 $280 Skyhawks: Flag Football 320552-A1 $242 Summer Fiesta 321058-A1 $272 Skyhawks: Cheer Camp 320553-A1 $242 Specialty Combo Camp Action and Minecraft Flix 321142-B1 $495 Video Game Design with Minecraft 321198-A1 $275 Week 4: July 15-19 Activity Name Barcode List Fee Your Fee Summer Kids Club FD Camp Hay Day 320301F-D1 $247 Summer Kids Club AM Camp Hay Day 320301A-D2 $150 Summer Kids Club PM Camp Hay Day 320301P-D3 $150 S.K.C. Local Trip Ice Skating, San Mateo 320306-D4 $32 S.K.C. Adventure Trip Exploratorium, San Francisco 320306-D5 $51 AM Specialty Camp Yoga and Art 321049-A1 $270 Rebound Basketball 320548-B1 $182 YouTube Stars! 321187-A1 $275 PM Specialty Camp Dragonfly Design: Art and Jewelry 321055-A1 $355 Stop Motion Minecraft Animation 321196-A1 $248 Cartoon Workshop 321578-A1 $272 Rallyball Tennis 320559-A1 $300 * Please submit with Registration Form on page 27. 28 CAMP HOTLINE 522-SUMM or www.sanmateorec.org

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 320940-A1 $315 320940-B1 $315 320940-C1 $230 320940-D1 $230 Pre Kamp - Shoreview PreK 320303-A1 $143 320303-B1 $86 320303-C1 $143 320303-D1 $143 320303-E1 $143 320303-F1 $143 Pre Kamp - Lakeshore PreK 320303-A2 $143 320303-B2 $86 320303-C2 $143 320303-D2 $143 320303-E2 $143 320303-F2 $143 Pre Kamp - Beresford PreK 320303-B3 $86 320303-C3 $143 320303-D3 $143 320303-E3 $143 320303-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 320560-C1 $400 320560-D1 $400 320560-E1 $400 320560-F1 $400 320560-G1 $400 320560-H1 $400 Fencing: Half Day AM 7-12 yrs 320560-C2 $225 320560-D2 $225 320560-E2 $225 320560-F2 $225 320560-G2 $225 320560-H2 $225 Fencing: Half Day PM 7-12 yrs 320560-C3 $225 320560--D3 $225 320560-E3 $225 320560-F3 $225 320560-G3 $225 320560-H3 $225 CA: Advanced Math 8-11 yrs 321179-A1 $340 321179-B1 $340 321179-C1 $340 CA: Adv. English: Word Choice & Fluency 8-11 yrs 321174-A1 $340 CA: Adv. Math & Public Speaking 8-11 yrs 321180-A1 $615 CA: Adv. Math & Adv. English 8-11 yrs 321180-B1 $615 CA: Adv. Math & Debate 8-11 yrs 321180-C1 $615 www.cityofsanmateo.org/summercamps 29 CA:Debate/Critical Thinking: Mock Trial 8-11 yrs 321178-A1 $330 CA: Public Speaking: Creative Interpret. 8-11 yrs 321175-A1 $340 321175-B1 $330 321175-A1 $330 Create, Mix & Mingle: Half Day AM* 5-13 yrs 321047-C2 $285 321047-D2 $228 321047-E2 $285 321047-F2 $285 321047-G2 $285 321047-H2 $285 321047-I2 $285 321047-J2 $285 Create, Mix & Mingle: Half Day PM* 5-13 yrs 321047-C3 $285 321047-D3 $228 321047-E3 $285 321047-F3 $285 321047-G3 $285 321047-H3 $285 321047-I3 $285 321047-J3 $285 Create, Mix & Mingle: Full Day* 5-13 yrs 321047-C1 $495 321047-D1 $396 321047-E1 $495 321047-F1 $495 321047-G1 $495 321047-H1 $495 321047-I1 $495 321047-J1 $495 ETC Children s Musical: Disney s The Jungle Book 6-9 yrs 320945-A1 $840 ETC Children s Musical: Seussical 6-9 yrs 320945-B1 $960 ETC Youth Musical: Disney s The Lion King 9-14 yrs 320946-A1 $810 ETC Youth Musical: Junior Musical TBD 9-14 yrs 320946-B1 $910 Fashion Design: Half Day 8-17 yrs 321052-A2 $410 321052-B2 $410 321052-C2 $410 321052-D2 $410 321052-E2 $410 321052-F2 $410 321052-G2 $410 Fashion Design: Full Day 8-17 yrs 321052-A1 $610 321052-H1, H2, H3 $140 321052-B1 $610 321052-C1 $610 321052-D1 $610 321052-E1 $610 321052-F1 $610 321052-G1 $610 Horse-Back Riding 8-14 yrs 320566-A1 $450 320566-B1 $360 320566-C1 $450 320566-D1 $450 320566-E1 $450 320566-F1 $450 320566-G1 $450 Indoor Rock Climbing 5-13 yrs 320562-A1 $155 320562-B1 $125 320562-C1 $155 320562-D1 $155 320562-E1 $155 320562-F1 $155 320562-G1 $155

30 CAMP HOTLINE 522-SUMM or www.sanmateorec.org 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 321147-A1 $300 Jr. Chef Stars-Let Them Eat Cake 7-12 yrs 321149-A1 $300 Jr. Chef Stars-United States of Appetites 7-12 yrs 321192-A1 $300 Jr. Chef Stars-Baking Championshpi 7-12 yrs 321193-A1 $318 Jr. Chef Stars: Future Celebrity Chef 7-12 yrs 321191-A1 $300 Jr. Chef Stars: Junior Master Chef 7-12 yrs 321150-A1 $318 Mad Science: Wacky Robots & Widgets 7-12 yrs 321162-A1 $272 Mad Science: Young Inventors 7-12 yrs 321160-A1 $272 Myriad Performing Arts 5-7 yrs 320941-A1 $465 320941-B1 $465 320941-C1 $465 320941-D1 $465 320941-E1 $465 Neighborhood Summer Fun 6-10 yrs 320302P-A2 $45 320302P-A3 $75 320302P-A4 $75 320302P-A5 $75 320302P-A6 $75 Pong Planet s Ping Pong 6-13 yrs 320569-A1 $365 320569-B1 $240 320569-C1 $365 320569-D1 $365 320569-E1 $365 320569-F1 $365 320569-G1 $365 Rallyball Tennis: NF Half Day 7-14 yrs 320558-A1 $265 320558-B1 $265 Rallyball Tennis: NF Full Day 7-14 yrs 320558-A2 $369 320558-B2 $369 320558-F3 $359 Rebound Basketball 5-11 yrs 320547-A1 $175 320547-B1 $155 320547-C1 $155 320547-D1 $155 Skyhawks- Multi Sport: NF Half Day 6-12 yrs 320570-A1 $456 320550-A1 $235 Skyhawks- Multi Sport: NF Full Day 6-12 yrs 320570-B1 $569 Skyhawks-Mini Hawk: NF Half Day 6-12 yrs 320551-A1 $217 Skyhawks-Mini Hawk: NF Full Day 4-7 yrs 320551-B1 $330 Techsplosion Minecraft Challenge 7-12 yrs 321170-A1 $300 Ultimate Frisbee Camp 8-14 yrs 320563-A1 $305 ViBO: Camp Allegro 6 yrs + 320944-B1 $435 320944-C1 $820 Youth Sailing 8-13 yrs 320572-A1 $475 320572-B1 $475 320572-C1 $475 320572-D1 $475 320572-E1 $475 320572-F1 $475 320572-G1 $475 * Classes start as early as 6/10. 321047 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) 11-13 yrs 320308-A1 $47 320308-A2 $47 320308-A3 $47 320308-A4 $47 320308-A5 $47 320308-A6 $47 320308-A7 $47 X-treme Summer Days (XSD) 10-13 yrs. 320307-A1 $304 320307-A2 $304 320307-A3 $304 320307-A4 $304 320307-A5 $304 320307-A6 $304 320307-A7 Leaders in Training (LIT) 13-17 yrs. 350404-A1 $130 350404-A2 $130 350404-A3 $130 350404-A4 $130 CAMPER NAME * Please submit with Registration Form on page 27. Myriad s Film Scoring 10-17 yrs. 320949-A1 $455 320949-B1 $455