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2010 PRINTABLE REGISTRATION FORM HOME \| 2010 SUMMER PROGRAM Child's name _________________________________________________________ M____ F____ HM Telephone_____________________ Grade in Fall 2010 _______ Age by 06/20/09 ______ Birthdate ____________________ TAG _______ Other _____________________ School ____________________________________________________________ District ____________________________________ Health information _____________________________________________________________________________________________ Physician's Name _________________________________________ Telephone ___________________________________________ Dietary restrictions (Please be very specific) _______________________________________________________________________ ____________________________________________________________________________________________________________ Parent/Guardian _______________________________________________________________________________________________ Street address ________________________________________________________________________________________________ City _________________________________________________________ State _______________________ Zip ________________ Cell #___________________________ Home #______________________________ Work # __________________________________ Email: _____________________________________________ Other contact information: ____________________________________ Emergency contact name and phone _______________________________________________________________________________ Person(s) authorized to pick up child(ren) after class __________________________________________________________________ Where did you learn about the Education Soaring Summer Program? _____________________________________________________ WRITE CLASS TITLE and WEEK #. CHECK IF ALL-DAY or just MORNING OR AFTERNOON. USE ADDITIONAL PAGES IF NEEDED. CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____ CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____ CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____ CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____ CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____ CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____ CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____ CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____ CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____ CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____ CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____ I understand that Education Soaring, Inc. occasionally takes photographs of children in classes for public relations purposes. Names of students are not used in Education Soaring literature. Permission is granted to use my child’s picture without his or her name in Education Soaring literature. Because the news media's policies regarding the use of children's names differs from Education Soaring's policies, I understand that my child will not be allowed to be photographed or interviewed by any media group without me or my representative present or without my permission granted in writing. Education Soaring instructors and volunteers hold exemplary records as dedicated teachers, volunteers and community citizens. Student safety is the top priority of all Education Soaring staff and every effort is made to ensure the well-being of participants in classes. I release Education Soaring, Inc., its officers, instructors, and volunteers from any and all liability for injury to my child arising out of his or her participation in the program. CHILD ____________________________ PARENT SIGNATURE __________________________________________ DATE ______________
BASIC TUITION for ALL CHILDREN in a FAMILY $ __________ Tuition x # of All-Day classes, 5days $ __________ Tuition x # of All-Day classes, 4 days $ __________ Tuition x # of Half-Day classes, 5 days $ __________ Tuition x # of Half-Day classes, 4 days $ __________ Total Tuition	CALCULATE FAMILY and FREQUENT-CAMPER DISCOUNT If total tuition is more than $1400 and less than $2000, deduct 5%. Total ________________ If total tuition is $2000 or more, deduct 10%. Total ________________	CALCULATE AMOUNT DUE $ __________ Materials Fees, if any $ __________ Total Tuition __________ TOTAL AMOUNT DUE
CREDIT CARD INFORMATION Visa ________ Mastercard _________ Exp. _______ /______ Card number _________________________________________________ Name of cardholder on card __________________________________________________________________________________________ Street address of cardholder including zip code __________________________________________________________________________

2010 PRINTABLE REGISTRATION FORM HOME | 2010 SUMMER PROGRAM

Child's name _________________________________________________________ M____ F____ HM Telephone_____________________

Grade in Fall 2010 _______ Age by 06/20/09 ______ Birthdate ____________________ TAG _______ Other _____________________

School ____________________________________________________________ District ____________________________________

Health information _____________________________________________________________________________________________

Physician's Name _________________________________________ Telephone ___________________________________________

Dietary restrictions (Please be very specific) _______________________________________________________________________

____________________________________________________________________________________________________________

Parent/Guardian _______________________________________________________________________________________________

Street address ________________________________________________________________________________________________

City _________________________________________________________ State _______________________ Zip ________________

Cell #___________________________ Home #______________________________ Work # __________________________________

Email: _____________________________________________ Other contact information: ____________________________________

Emergency contact name and phone _______________________________________________________________________________

Person(s) authorized to pick up child(ren) after class __________________________________________________________________

Where did you learn about the Education Soaring Summer Program? _____________________________________________________

WRITE CLASS TITLE and WEEK #. CHECK IF ALL-DAY or just MORNING OR AFTERNOON. USE ADDITIONAL PAGES IF NEEDED.

CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____

CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____

I understand that Education Soaring, Inc. occasionally takes photographs of children in classes for public relations purposes. Names of students are not used in Education Soaring literature. Permission is granted to use my child’s picture without his or her name in Education Soaring literature. Because the news media's policies regarding the use of children's names differs from Education Soaring's policies, I understand that my child will not be allowed to be photographed or interviewed by any media group without me or my representative present or without my permission granted in writing.

Education Soaring instructors and volunteers hold exemplary records as dedicated teachers, volunteers and community citizens. Student safety is the top priority of all Education Soaring staff and every effort is made to ensure the well-being of participants in classes. I release Education Soaring, Inc., its officers, instructors, and volunteers from any and all liability for injury to my child arising out of his or her participation in the program.

CHILD ____________________________ PARENT SIGNATURE __________________________________________ DATE ______________