SRVRTC Summer Camp 2019
Choose one from Below *
Student First Name *
Student Middle Name
Student Last Name *
Student Street Address *
Student City, State and Zip *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Age (As of June 30, 2019) *
Fall 2019 Grade Entering *
What School are you coming from? *
Students Home Phone *
T-Shirt Size (Adult Sized Shirts) *
Contact 1 First Name *
Contact 1 Last Name *
Street Address *
Town/City *
State *
Zip Code *
Home Phone
Work Phone
Cell Phone
E-Mail address
Occupation
Employer
Contact # 2 First Name
Contact # 2 Last Name
Street Address
Town/City
State
Zip Code
Home Phone
Daytime Phone
Cell Phone
Email Address
Occupation
Employer
Child live with *
Person responsible for payment *
Please list those people including in addition to parents/guardians who are permitted to pick up your child: *
Medical Release Information
Insurance Information
Policy Number *
Name of Health Insurance Provider *
Primary Physician *
Address *
Phone *
Hospital Preference *
Please list any medical problems, including requiring maintenance medications (i.e. Diabetic, Asthma, Seizures.)
Medical Problem #1
Required Treatment #1
Should Paramedics be called? #1
Clear selection
Medical Problem # 2
Required Treatment #2
Should paramedics be called? #2
Clear selection
Is your student presently being treated for an injury or sickness, or taking any form of medication for any reason? *
If yes to previous question explain
Is your student allergic to any type of food or medication? *
If yes to allergic questions please explain
Does your child require a special diet?
Clear selection
If yes to special diet please explain
The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.
In case of medical emergency contact:
Contact #1 (Name/Phone/Relationship to Child) *
Contact # 2 (Name/Phone/Relationship to Child)
Contact # 3 (Name/Phone/Relationship to Child)
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill *
Required
I understand that the Sugar River Valley Region Technical Center or SAU 6 will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian *
Required
TUITION INFORMATION: $25.00 payable by Check or Cash to the SRVRTC
Address: 111 South Street
Claremont, NH 03773
Parents seeking needs based scholarship for the $25.00 fee must email the Director at aherzog@sau6.org and provide evidence of need.
Terms of Agreement
Photo Release
I hereby give permission for my child to be photographed during the SRVRTC Summer Camps. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Sugar River Valley Regional Technical Center. *
Required
Camper Expectations
Student who are attending the Sugar River Valley Regional Technical Center (SRVRTC) – Claremont NH will be expected to adhere to the rules of the current Claremont Middle School Parent Student Handbook. Students are expected to come prepared with appropriate clothing as specified by the program. Both Construction Carpentry and Culinary require students to wear long pants, shirt with sleeves (No Tank Tops) and closed toe shoes. Culinary students will also need to wear a hat during kitchen time. Students will be provided safety glasses and expected to wear them. Safety is the utmost concern for us at the SRVRTC. Any intentional safety violations by the student and or disciplinary problem will result in removal from summer camp at the sole discretion of the Director of the SRVRTC and forfeiture of paid tuition. *
Required
Student Electronic Signature *
Parent/Guardian Electronic Signature *
Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This form was created inside of SAU6. Report Abuse