SCCS summer camp registration form
Name: 


A red asterisk (*) indicates required questions.

  1. Child’s Name in English(Last, First): *


  1. Child's Chinese Name: *


  1. Gender*
    male
    female


  1. age (By August 1, 2012)*
    5
    6
    7
    8
    9
    10
    11
    12
    13
    14
    15
    more than 15
    less than 5


  1. Current grade at regular school (By June, 2012) *
    Kintergarten
    1
    2
    3
    4
    5
    6
    7
    8
    other


  1. Current grade at Chinese school (By June, 2012) *
    Kintergarten
    1
    2
    3
    4
    5
    6
    7
    8
    No applicable


  1. your address*


  1. Mother/guardian name*


  1. Mother/guardian phone number*


  1. father/guardian name*


  1. Father/guardian phone number*


  1. parent email address*


  1. Camp session 1: August 13-17, 9am-4pm
    Camp fee: $250*
    Yes, my child will attend
    No, my child will not attend


  1. Pre-camp (8-9am) or/and After camp (4-6pm) for session I
    Additional Fee: $20*
    Yes, my child will attend
    No, my child will not attend


  1. Camp session 2: August 20-24, 9am-4pm
    Camp fee: $250*
    Yes, my child will attend
    No, my child will not attend


  1. Pre-camp (8-9am) or/and After camp (4-6pm) for session 2
    Additional Fee: $20*
    Yes, my child will attend
    No, my child will not attend


  1. Emergency Contact Information
    In case of emergency, please list two responsible adults who could be notified by the school.
    Name and phone number*


  1. Doctor’s name and contact Phone *


  1. Allergies or other medical conditions the school should know: *


  1. Photo Release Agreement
    I grant to Southern Connecticut Chinese School (SCCS) the right to take photographs of my child in this Chinese summer camp. I authorize SCCS, its assigns and transferees to copyright, use and publish the same in print and/or electronically.
    I agree that SCCS may use such photographs of my child without his/her name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.*
    Yes
    No


  1. Parent/Guardian agreement
    I, the undersigned parent or legal guardian of the above child(ren) do give my permission and approval for his/her participation in SCCS Chinese School program(s) and therefore, assume all risks and hazards incidental to such participation. On behalf of my child(ren) and family, I freely and voluntarily agree to release, indemnify and hold harmless, the SCCS Chinese School, its directors, officers, administrators, teachers, and volunteers from any liabilities arising from any incident to my child(ren)'s involvement and participation in the school's program(s). I also have read and understand SCCS Chinese School’s Admissions Policy, Refund Policy, and Policies and Procedures on the SCCS Chinese School web site (http://www.ynhchineseschool.org). I understand that if my child displays inappropriate behavior, he/she (or I) may be dismissed from the program and no refunds will be given. *
    Yes
    No


  1. Please submit a current copy of Physical or Health Form (as of 8/1/2012; available from your physician), it is required on or before the program start date (8/13/2012). *
    Yes, I will
    No


  1. Payment: Please mail the $20 registration ($40 after Aug 1, 2012)and payment check to:

    Summer Section 2012
    Southern Connecticut Chinese School
    P.O. Box 2097
    74 Washington Avenue
    North Haven, CT 06520
    *
    Yes, I will
    No