Home>Summer Camp Registration FormSummer Camp Registration Form Student’s Full Name (required) Select Date of Birth (required) Current grade at the day school (required) Home Phone (required) Parent’s Name (required) Cell Phone (required) Email (required) What language(s) are primarily spoken at home? Does your child have any background in reading/writing in Persian? How well does your child speak/understand Persian? NoneBasic VocabularyFluentOther Does student have any allergy or significant health problems? NoYes please explain Please include any special information about your child that you believe we need to know:Emergency Contact (someone other than parents or guardian)Name Phone Number PHOTO RELEASE I hereby grant EveCina Foundation to use my child’s photographvideo in any of its publications and other media (e.g., website, brochure), whether now known or hereafter existing, controlled by EveCina Foundation. I will make no monetary or other claim against EveCina Foundation for the use of the photograph(s)/video*.Name (print full name): Signature: Waiver and Release From LiabilityI am the parent of (“my child”) who is, or will be attending EveCina foundation Summer Camp . I understand that during this Program, my child will be involved in activities including but not limited to: indoor and outdoor activities, games, dancing, art, and numerous other physical activities, any of which may result in injury or illness. By signing this form, I agree to release EveCina Foundation, the owner/lessor and/or lessee of the facility being used, and their associates, employees, volunteers, and independent contractors from any and all liability connected with the program. I understand that in the case of an accident involving my child, the emergency contact information that I provide will be used to contact me. If I cannot be contacted, I grant persons associated with the Program or the director of the facility my child attends, with the power to determine what medical treatment is reasonable necessary. In the event of an accident or medical emergency, I will be financially responsible for any medical and transportation expenses involved. In consideration of being permitted to the Program, on behalf of myself, my family, my heirs and my assigns, I hereby release the Program, its volunteers and contractors from liability for injury, loss or death to the above-mentioned participant while attending the Program now or in the future, resulting from the ordinary negligence of the Program and its associates. By signing this waiver I am promising that I have read and agreed to the contents of the waiver.Parent Signature: Date: Summer Camp: Tuesday, Wednesday, ThursdayWeek 1: June 11-12-13 Week 2: June 18-19-20 Week 3: June 25-26-27 Week 4: July 2-3-4 Week 5: July 9-10-11 Week 6: July 16-17-18 Week 7: July 23-24-25 Week 8: July 30-31 August 1Program starts: Program Ends: Time of classes: 9AM - 2PMAdditional Class/Time: Program Tuition: $170/weekAdditional class cost: Total: Early bird registration: $150/week Siblings discount: $10 off each siblingLate Pick-up Fees (after hours): Parents picking up children after 2:15 PM will be charged a late fee of $1.00 per minute, per child with no cap. Late fees are payable in cash to the closing teacher upon pick up. Unpaid late pick up fees will be billed to the child's account balance. There will be no tuition refund after:Signature of Parent/Guardian: Date For the Summer Camp Registration please select the applicable link(s) below:Pay general registration fee ($170 per person)Pay per person ($160 per siblings)If PayPal service is down, please pay in person.