EASTSIDE ACADEMY

Summer Camp 2016 Registration

Mondays

Tuesdays

Wednesdays

Thursdays

June 20, 27 July 11,18

June 21. 28 July 5,12

June 22, 29 July 6, 13

June 23, 30 July 7,14

Things that GO BOOM

9:00-10:30

Life Cycles
9-10:30

Star Wars
9-10:30

Music Camp
9-10:30

Life Cycles
11:30-1:00

Zoology
11:30-1:00

Math Fun
11:30-1:00

Things that GO BOOM

11:30-1:00

Music Camp
2:00-3:30

Explorers
2:00-3:30

3D Arts & Crafts

2:00-3:30

Star Wars
2:00-3:30

Camp #1: ______________________ Day: _________________ Time: ____________________

Camp #2: ______________________ Day: _________________ Time: ____________________
Childs Name: _________________________________________________________________
DOB: ________________

Age: _________________

Grade Level (entering): __________

Address: ______________________________________________________________________
City/Zip: ______________________________________________________________________
Home Phone: ____________________________ Cell Phone: ____________________________

Parent name(s): ________________________________________________________________

Cell phone that can be reached on the day of camp: ___________________________________
Alternative/Emergency Phone name and number: _____________________________________
Allergies (food or other): ________________________________________________________
_____________________________________________________________________________
Special needs: _________________________________________________________________

Mail Registration Forms and $50 per camp to:

Kris York 6113 Westmoreland Ln Pasco, WA 99301
Contact numbers: Kris York- 380.8607 / Michelle Tvedt- 460.9522

REGISTRATION DEADLINE IS 7 DAYS PRIOR TO CAMP START DATE

Eastside Academy
Summer Camp 2016 Liability Waiver Form
Name of Student: _______________________________________ Date of Birth: __________________
Parent (s) / Guardian (s): ________________________________________________________________
Address: _____________________________________________________________________________
Phone (Home):_________________Phone (Work): _________________Cell: ______________________
Emergency Contact and Phone: ___________________________________________________________
E-mail:_______________________________________________________________________________
Health Insurance Company and ID number: ________________________________________________
Special Health Care Needs: ______________________________________________________________
RELEASE AND WAIVER: As the parent or legal guardian of the above minor child, (hereinafter referred to
as my child), and in exchange for the benefits to be derived by my childs participation in this activity
sponsored by Eastside Academy, I agree, on behalf of myself and my child, to the following:
I hereby grant my permission for my child to participate in the specified activity and I am fully aware of
the nature of this activity and hereby elect to allow my child to voluntarily participate. On behalf of
myself and my child, I voluntarily assume all responsibility for any risks of loss, property damage, or
personal injury, that may be sustained by me or my child, or any loss or damage to property owned by
myself or my child, as a result of my child being engaged in the activity, whether caused by the
negligence of the organization or its volunteers, agents, or otherwise.
On behalf of myself and my child, as well as our respective estates, heirs, administrators, executors, and
assigns, I hereby release, waive, discharge and covenant not to sue the Eastside Academy or its
operators, from any and all liability, claims, demands, actions, and causes of action whatsoever arising
out of or related to any loss, damage, or injury, that may be sustained by me, or my child, to any
property belonging to me or my child
HEALTH CARE AUTHORIZATION: The undersigned hereby authorizes the operators of Eastside Academy
to perform any acts which may be necessary or proper to provide emergency health care of any student
in the event that the parent/guardian and/or emergency contact cannot be reached, including consent
to and authorization of medical procedures by qualified, licensed physicians, dentists, hospital or other
emergency medical personnel, as they, in the exercise of their profession and in their sole discretion,
may deem necessary. The undersigned understands that (s)he is responsible for all costs and expenses
of such medical treatment.
In signing this agreement, I acknowledge and represent that I have read and understand it.
Childs Printed Name_____________________________________________________________
Parents Printed Name ____________________________________________________________
Signature______________________________________________________ Date____________