STUDENT APPLICATION
SOUTHERN CALIFORNIA SPACE AND SCIENCE CAMP, August 8-12, 2016
PRESENTED BY: LEARNING ENRICHMENT AFTERSCHOOL PROGRAM, INC (501c3)PLEASE PRINT and fill in completely:
Camper Information
Name: Date of Birth:
Address: City:
State: Zip: Male Female
Phone: Email:
Name of School: Grade: Shirt Size
Guardian Information
Name: Relationship:
Contact numbers: Home: Cell: Office:
Email:
In Case of Emergency Notify
Name: Relationship:
Address: City: State: Zip:
Emergency Phone Number:
CAMP ITINERARY (Locations may change)
August 8: Columbia Memorial Space Center, DowneyAugust 11: Virgin Galactic, Boeing Aircraft, Long Beach
August 9: Jet Propulsion Laboratory, PasadenaAugust 12: California Science Museum, Los Angeles
August 10: Vandenberg AFB, Lompoc, CA
A registration packet with details of each visit will be given to all completed registrations prior to the camp initiation. Campers will be exposed to scientists and engineers in their environment and get hands on experience from these experts. Materials will be given to the participants at several of the site visits. Students will be asked to participate in all activities, and those most motivated participating will be identified for potential camp scholarships (awarded based upon availability). Cost: $60.00 per camper. Make checks payable to: Learning Enrichment Afterschool Program “Camp 2016”
Mail to: Post Office Box 44986, Los Angeles, California 90044-2337 (Attn: SoCal Space Camp, 2016)
Application must be received by June 24, 2016. Tax deductible donations are accepted.
THIS IS A DAY CAMP. Transportation is included in this package with local transportation to be both individually required with some group transportation possible. We encourage carpooling and networking where possible.
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2016 Space and Science Waivers and Releases of Liability
Learning Enrichment Afterschool Programs, Inc. (501c3) (“LEAP”) requires participants in this Southern California Space and Science Camp – 2016 (“Camp 2016”) read, fully understand, and sign these following releases in order for campers to participate. It is recommended that all campers be fully aware of any medical conditions that may interfere with their participation:
RELEASES:
In consideration of being allowed to participate in any way in the “Camp 2016”, related events and activities, the undersigned acknowledges, appreciates and willingly agrees that:
- I will comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately.
- I acknowledge and fully understand that each participant will be engaging in activities which may require care and caution and that I will accept responsibility for damages for any negligence that I engage in which results in damages to the premises, equipment, or fellow campers.
- I hereby authorize and give my full consent to “Camp 2016” to copyright and/or publish any and all photographs, videotapes, and/or film in which I may appear while attending any “Camp 2016” activity. I further agree that “Camp 2016” my transfer, use or cause to be used, these photographs, videotapes, or films for any exhibitions, public displays, publications, commercials, art and advertising purposes, and television programs without limitations or reservations. I waive any right to inspect or approve the finished product, including written copy that may be created in connection therewith, in consideration of $0.00 receipt of which is acknowledged.
- I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release, and agree to hold harmless “Camp 2016”, its officers, other participants, sponsoring agencies, advertisers, donors, and, if applicable owner and lessors of premises used to conduct the event, all of which are hereinafter referred to as “releases”, with respect to any injury, disability, death or loss of damage to person or property, whether arising from the negligence of the releases or otherwise, to the fullest extent permitted by law. I will indemnify, save and hold harmless above named releases of, from and against any loss, cost, expense, damage or liability that such releases may incur as a result of, arising from or in connection with such claim, including without limitation any attorney’s fees, or other costs or expenses or litigation.
- I knowingly and freely assume all such risk, both known and unknown, even those arising from the negligent acts or omissions of others, and assume full responsibility for my participation.
I have read this release of liability and assumption of risk agreement, fully understand its terms, and understand that I have given up substantial rights by assigning it and sign it freely and voluntarily without any inducement.
Participant’s Signature (even if under 19)Date
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to indemnify and hold harmless the releases from any and all liabilities incident to my minor child’s involvement or participation in these programs above, even if arising from their negligence, to the fullest extent permitted by law.
Parent/Guardian SignatureDate
Print Name
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MEDICAL WAIVER:
These pages must be completed and returned to Camp 2016 with the full camp payment prior to YOUR participation in “Camp 2016”. YOU WILL NOT BE ADMITTED WITHOUT THIS FORM COMPLETED IN ITS ENTIRETY.
Camp Details:
Southern California Space and Science Camp, August 8-12, 2016. Designed for up close and personal interaction between students, scientists, and engineers from surrounding companies, agencies, private organizations, and public institutions to enhance the awareness of scientific and engineering principles in the learning cycle for student participants.
Camper Details:
Name: Date of Birth: Age:
Address: Zip:
Emergency Contact:
PrimarySecondary
Name:
Phone:
Address:
Email:
Medical Information:
Has the camper had any of the following? (Please check which applies)
Medical:Immunization:Allergies:
Chicken Pox ____Tetanus Toxiod ___Insect Stings___
Diabetes____Tuberculin Test ___Penicillin___
Measles____Measles/Rubella ___Antibiotics___
Asthma____Polio Vaccine ___
Epilepsy____Other:Other:
Other:
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Will the camper be taking any medication during camp? (What and when?)
Please list any medications and in what quantity they should be administered?
Are there any medical conditions that will require special attention?
Physician’s Name: Phone:
Address: City/State/Zip:
Insurance Information:
Carrier:Policy Number:
Policy Holders Name:Group Number:
Liability Waiver:
In signing this waiver of liability, I release “Camp 2016”, the host institution, and all other involved parties from any claims or responsibility for injuries suffered in Camp 2016 activities. I knowingly assume all risks associated with participation, even if arising from negligence of the participants or others, and assume FULL responsibility for my participation. I certify that I am in good physical,medical condition and can participate in this “Camp 2016”. Further, I authorize the site director or his/her designee to request treatment as necessary to insure my well-being.
Participants Signature:
Print:
Date:
Southern California Space and Science Camp, August 8-12, 2016, is an activity by Learning Enrichment Afterschool Programs ( a 501c3 entity formed in 2004 under the state of California laws, with offices at 112 West 9th Street, Los Angeles, California, 90015. Point of Contact for “Camp 2016” is Craig Mobley, and/or , 323-758-3200. The application period closes on June 24, 2016 unless otherwise extended by permission from LEAP through communication with Craig Mobley.
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