PARTICIPANT  INFORMATION

Summer Camp Dates _________ July 7^th , , 2009   through  August 15^th , 2009

Fall             ________________September 28^th through December 12^th, 2009 

Name_________________________________________     

School  ID #_________________________

Address_________________________________________________________

City______________________ State _______________ Zip ______________

Phone ___________________ Student Email __________________________

Birth date   _______________________         Age ______________

Grade in September 2009_______ School ____________________________

Other affiliate youth organization  __________________ _________

Parent/Guardian 1 _________________________  Email  _________________

Daytime Phone ____________________ Cell Phone ____________________

Parent/Guardian 2 _____________________________ 

Email_______________________

Daytime Phone ____________________ Cell Phone ____________________

EMERGENCY CONTACT

If I cannot be reached in the event of an emergency, the following person is authorized to act on my behalf:

Name ____________________ Relationship to  participant _______________

Daytime Pho____________________ Cell Phone ____________________

Parent/Guardian Signature ________________________________________

________________________________________          _________________

Name of Adult Participant                                                          T-Shirt Size

For Office Use Only
Program Cost    $ ______   Check/Credit     $ ______ Total Enclosed  $ ______	Date  ____ / ____/ ___ Amount    $ ________ Receipt #    ________	Date ____ / ___/ ____ Amount    $ ________ Receipt #    ________

Program Schedule    M—F @ 4:00 PM to 8: 00 PM) Sat: (11:00AM to 3:OO PM

(Please specify classes you will like to enroll in:)

Math Tutoring                 k-12  (2hrs x twice a week )                                 □

Reading Tutoring            k-12  (2hrs x twice a week )                                 □

Robotics & Rocketry       k-12  (3hrs x once a week  )                                □

PERMISSION FORM

My child has my permission to participate in all program activities.

Waiver:  I will not hold R&R Information Systems LLC responsible for any accident unless if it is due to negligence on the part of R&R Information Systems LLC staff or counselors.  There is a $25.00 registration fee that is nonrefundable.

_____________________    _______________________    _______________

Child’s Name                        Parent/Guardian Signature                              Date

Images of  participant may be used in our organization relations

□ Yes          □ No    Parent/Legal Guardian Signature ______________________

PAYMENT

Cost of program         $ 80.00/wk/Sub   Staff 10% Discount credit ( $  2.50 ) Scholarship Credit           ( $             )  Number  of hours            _________ Total Cost (Hours x $25.00)              _________

Check/Credit Card   $ ___________   Camp Staff Credit    $ ___________ Scholarship Credit    $ __________ (Voucher must be attached)   Amount Enclosed  $ ___________

If using charge  card, please complete the following information:

____________________________       $ ____________________

Credit Card #                                          Amount Applying Towards Summer Program

___________________________________                  _____________________

VISA or MasterCard Number                                               Card Expiration Date

___________________________________     $ ____________________

Print Card Holder’s Name                                          Amount of Charge

__________________________________________      _____________________

Cardholder Signature (for credit card charges only)                   Date