2014 Summer Camp Application Form Waiver and Release
Participant’s Name: ______________________________________
Parent/Guardian Name: __________________________________
Tel #: ______________________ Cell #: _____________________
Email Address: _________________________________________
Emergency Contact: _____________________________________
Tel #: ______________________
Event: Sport & Outdoor Activities & Field Trip
In consideration of the acceptance of the above entry in Yip’s Music & Mon-tessori Elementary Private School, of whom I am the legal guardian, and the permission to participate in the outdoor programs organized by Yip’s Music & Montessori Elementary Private School. I hereby waive and forever discharge the Yip’s Music & Montessori Elementary Private School, the sponsors, representatives, their agents, officers, employees and any other person or organization assisting in the event from all claims, damages, costs and expenses in respect to damages or injury suffered by my/their person or property, however caused, which may occur as a result of my/their participa-tion in the program in any location where the program is being held (i.e. sports & outdoor activities & field trips). I acknowledge and agree that the Yip’s Music & Montessori Elementary Private School may use photographs of the participants therein for promotional purposes.
_____________________________Parent/Guardian Signature
____________________________________Date
____________________________________ Witness
Address: _______________________________________________
_______________________________________________
Home #:
Term Date Camp FD / HD Fee
Extended Hours ($5 / session):7:00 - 9:00 a.m. &/or 4:00 - 6:30 p.m.
Lunch Fee ( $5 / meal ):
Material Fee ( $5 / week - HD, $8 / week - FD ):
Payment Method: TOTALCheque # ________ or Cash Date: ___________________ ( mm/dd/yyyy )
Allergy: _______________________________________________
Name: (Eng) _____________________________
(Chi) _____________________________
Sex: (F/M) _____ Age: _____ DOB: _________________ mm / dd / yyyy
For Officer Use Only:
Preschool Camp - Piano or Violin (over 3.9 yrs old) / Percussion - Nap / No NapMusic Camp - Piano / ViolinP.M. Session - Cantonese / Mandarin
