Summer of Wonder

Summer Learning from Experience Possible

Registration Form
Students Name__________________________________________Birthdate___________Grade for 2015_______
Address_________________________________________________________City___________________________
State_______Zip___________ Gender: (circle) M F T Shirt Size: (circle) S M L XL
Parent One: Last Name _________________________________First Name_______________________________
Address__________________________________________________________City_________________________
State_______Zip____________Daytime Phone______________________Home Phone_______________________
Cell Phone_______________________E-mail______________________________
Parent Two: Last Name _________________________________First Name_______________________________
Address__________________________________________________________City_________________________
State_______Zip____________Daytime Phone______________________Home Phone_______________________
Cell Phone_______________________E-mail______________________________
Child resides with (circle) Both Parents
Other_________________

Joint Custody

Mother

Father

Emergency Contact One: Last Name _____________________________First Name_________________________

Address__________________________________________________________City_________________________
State_______Zip____________Daytime Phone______________________Home Phone_______________________
Cell Phone_______________________E-mail______________________________
Emergency Contact Two: Last Name _____________________________First Name_________________________
Address__________________________________________________________City_________________________
State_______Zip____________Daytime Phone______________________Home Phone_______________________
Cell Phone_______________________E-mail______________________________
Doctors Name_____________________________________________________Phone______________________
All other persons authorized to pick up your child from Summer Learning:
Name:_________________________________________________Relationship____________________________
Name:_________________________________________________Relationship____________________________
Name:_________________________________________________Relationship____________________________
Name:_________________________________________________Relationship____________________________
Please tell us in full about any medical/health and/or behavioral conditions, past or present, and any other
pertinent information that might aid in the enhancement of your childs camp experience. Us a separate sheet as
necessary. We strive to meet the needs of children with various needs, but need your full input to succeed.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Permission & Liability Waiver:

My child, _____________________________________, has permission to fully participate in Experience Possibles
Summer of Wonder summer learning activities during the 2014 summer term. I, as a parent/legal guardian, do
hereby grant the Experience Possible staff and designated adults the right to authorize emergency medical
treatment for my child in the event that I or my designated representatative cannot be reached. I agree to hold
harmless Experience Possible and its agents from liability resulting from an accident.
I hereby grant permission for staff to take whatever steps may be necessary to obtain emergency treatment for my
child. These steps may include, but are not limited to, the following:
1. In a life-threatening emergency or urgent situation, staff will call 911 before making any attempt to contact
parents.
2. For a non-life threatening emergency, we will attempt to call the parent/guardian first, and if we cannot reach
them, we will attempt to contact the Emergency contacts listed on the Emergency Information form. If we cannot
make an appropriate contact, we will call paramedics or the childs health care provider.
I understand that Experience Possible and staff will not be responsible for anything that may happen as a result of
false information provided by parents/guardians, or as a result of the parent/guardians failure to provide
information at the time of enrollment. I understand that staff will not administer drug or medication without
specific written & signed instruction from the health care provider and/or the childs paren/guardian.
Enrollment for your child in the Summer of Wonder Summer Learning constitutes your agreement to this waiver.

___________________________________________________________________________________________
Signature Parent/Guardian 1
Date
Signature Parent/Guardian 2
Date
___________________________________________________________________________________________
Print Parent/Guardian 1
Date
Print Parent/Guardian 2
Date

Publicity Release Form: I authorize Experience Possible to use a photograph or other image
of my child for public relations purposes connected to this summer learning program and
future programs associated with Experience Possible. I understand that my childs name will
not be published with an image.

_________________________________________________________________________________________________________
Signature Parent/Guardian 1
Date Signature Parent/Guardian 2
Date

Deposits/Fees: We enclose a registration fee of $200 ($25 per week ). We understand that this Deposit
is non-refundable after June 6, 2014. Deposits may be transferred to another person.
Cost:

Full Scholarship Students--$150/week (registration fee $100)

Base Scholarship--$150/week (registration fee $200)
Partial Scholarship--$200/week (registration fee $200)
Base Cost$230/week (registration fee $250)

Scholarships are given for either need OR merit. Email the Lead Instructor for directions on how to
apply at PossibleAndBeyond@gmail.com. Almost all students receive financial aid.
Balance of payment: Payment for each weeks study and enrichment must be received by Experience
Possible (2) weeks prior to the start of said week. Failure to adhere to this requirement may result in
loss of deposit and/or loss of students reservation for the entire session. Exceptions may be made;
these must be in writing and signed by both of the adults responsible for payment and the Director of
Experience Possible.
Non-Sufficient Funds:

A $35 fee will be charged for any checks returned due to insufficient funds.

Withdrawals/Cancellations: Notifications of cancellation must be received by Experience Possible no

later than two weeks prior to the start of study and enrichment. The family is responsible for the first
half of the tuition if the student withdraws less than two weeks prior to the start of the session. The
family is responsible for the value of half of a session if the participant leaves early or the remaining
balance if the young learner leaves in the second half of the program
Group Assignment: Each participant will be assigned to the appropriate program based on the grade
s/he will be entering in fall 2014.
Alpha Group Scholars entering grades 6-7
Omega Group Scholars entering grades 8-9
Instructors-in-training Scholars entering 12 Freshman
Each group has limited enrollment. Please mail this form as soon as possible