2017 Registration Form Child Information

Transcription

1 2017 Registration Form Child Information Full Name Address City State Zip Grade (Fall 2017) Age Gender Birthdate / / Current School T-Shirt Size Parent/Guardian Information Mother s Name Father s Name Phone Numbers and Contact Information Home Cell Work Please Sign the Liability and Media Waiver Statement As a parent or guardian of the participant named above, I give my permission for my child/ward to participate in the activities relative to The Webb School programs. I hereby waive and release The Webb School and all employees of The Webb School from any and all liability for any loss or damage in any injury, illness or other condition arising out of my child s participation in any of the Webb summer programs. I give The Webb School permission to use my child s name and/or photographic/electronic image to promote The Webb School in any electronic or print media, in news/photo releases and advertisements distributed to media outlets, and internal/external school publications and marketing materials, (i.e.: The Webb School Facebook Page, The Webb Magazine, The Webb Beat E-Newsletter, etc.). Signature Parent/Guardian Date How did you find out about our programs? Direct Mail Alumni Advertisement Parent Website/Online Other Payment Method of payment: Check enclosed MC Visa Credit card no.: Expiration date: Amount to be charged on credit card: Name on card: Signature: $25 Off for attending each additional week. This does not include sports camp. Please send completed form and check payable to: The Webb School Attn: Summer Programs Post Office Box 488 Bell Buckle, TN Register today at For more information, contact or admissions@webbschool.com.

2 The Webb School Summer Programs 2017 Registration Form Day Camp Rising 4th-8th graders $275 per week (includes lunch and 2 t-shirts) $25 Off for attending each additional week. Day Camp Schedule 8:45-9:00 - Morning announcements at gym 9:00-10:15 - Session 1 10:15-10:25 - Snack 10:25-11:40 - Session 2 11:40-12:10 - Lunch 12:10-1:25 - Session 3 1:25-1:35 - Snack 1:35-2:50 - Session 4 2:50-3:00 - dismissal at gym * Parent program on Friday Day Camp Week One June LEGO Robotics Level 1 Outdoor Adventures Pottery Inspirational Math 1 Murfreesboro Bus $35 (departs at 8:00 a.m.) Tullahoma Bus $35 (departs at 8:00 a.m.) Day Camp Week Three June Engineering Challenges Outdoor Adventures Pottery Inspirational Math 1 Murfreesboro Bus $35 (departs at 8:00 a.m.) Tullahoma Bus $35 (departs at 8:00 a.m.) Day Camp Week Two June Inspirational Math 2 Outdoor Adventures Pottery LEGO Robotics Level 2 Murfreesboro Bus $35 (departs at 8:00 a.m.) Basketball Skills Camp Rising 4th-12th graders Join Webb Varsity Boys Basketball Coach, Jeff Mitchell, as he focuses on offensive skill development. There will be competitive games, drills, and activities. Campers receive a t-shirt, certificate, and lunch the last day. June 5-7 9:00 a.m.-noon $80 or $30 per day Tullahoma Bus $35 (departs at 8:00 a.m.)

3 The Webb School Summer Program Course Descriptions Summer 2017 OUTDOOR ADVENTURES Mornings filled with high and low ropes, zip line, climbing and more! Push yourself to your limits with our trained staff. Activities will be designed for fair or foul weather. POTTERY Learn how to throw on the pottery wheel. This hands-on course is taught by an experienced potter. Use your imagination and enjoy the creative and messy process. Take home your creation Friday! INSPIRATIONAL MATH 1 AND 2 This is a program designed at Stanford University that is formulated to inspire students to achieve a growth mindset through beautiful and creative math. All tasks are designed to be low floor and high ceiling so all students can have success and go as far as they are able. Class 1 is not required for 2, they will just have a different week. LEGO ROBOTICS LEVEL 1 The robotics kits are designed for beginners and the more experienced builders. This course is designed for an introduction to the build and design process with a small amount of programming. Create a moving robot to move around by the end of the week. LEGO ROBOTICS LEVEL 2 Level 2 robotics takes the building and programming to the next level. You will work with and modify the stock robots built in Level 1 and get into more of the programming to make them do more! Level 1 is not required to participate. ENGINEERING CHALLENGES Each day will be a new challenge for you and your group to figure out and solve a problem to the best of your ability. We provide the problem and materials, and you provide the brains! Will you be the engineering champion at the end of the week?

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6 8. Epi-Pen required? o Yes o No If yes, please be sure the Student/Camper has one with him or her during the duration of his or her time at The Webb School. Please make the Instructor and/or Nurse aware of where it is located. 9. Please list all Over-The-Counter Medications or other that you DO NOT want your child to be given while on The Webb School campus and/or in the care of any Webb School personnel. 10. Please list any additional info or comments that may be helpful in caring for your child: **PLEASE ATIACH A COPY OF INSURANCE CARD (FRONT AND BACK) TO THIS FORM** Name of Insurance Co.: Group #: Policy Holder Info: / / Name SS# or ID # Date of Birth (M/D/Y) Student's Primary Physician: Phone# General Release I/We having had my son/daughter properly examined by a physician do hereby give permission for my son/daughter to participate in any sport, activity, or trip offered as a part of The Webb School program with the exception(s) of: I/We hereby acknowledge that such participation in recreational and instructional programs and activities may involve certain inherent risks of physical injury, and I assume responsibility for all such risks. The undersigned hereby agrees that in giving permission for participation in school-sponsored activities the undersigned does hereby release, indemnify, hold harmless, and forever discharge The Webb School and the Board of Trustees of The Webb School, its members individually, and its officers, agents and employees from any and all claims, demands, regrets, and causes of action of whatever nature or kind, arising from and by reason of any and all known and unknown, foreseen and unforeseen bodily and personal injuries and consequences thereof, resulting from participation in or in any way connected with such programs and activities. I/We authorize The Webb School nurse, or employee in charge to sign for my son/daughter to receive any emergency medical treatment or other medical care that might be deemed necessary. Consent is given for The Webb School or any Emergency Medical Care Center and its personnel to request any needed medical information or records on my son/daughter that may be needed to best care for my child. Consent is given for medical information to be given on an as-needed basis to the Faculty/Staff of The Webb School in order to best care for my son/daughter while in the care of the Faculty/Staff of The Webb School. Diligent efforts will be made to contact parent(s)/guardian(s) before any medical treatment is given. Medication Permit I/We give permission to The Webb School personnel to assist my child in self-administration of non-prescription and/or prescription medication as needed. My son/daughter is competent to self-administer non-prescription and/or prescription medication with assistance. In granting this permission and consent, I/We hereby waive, release and hold harmless The Webb School and all school personnel (individually) from any and all actions, cause of action, claims and demand for damages, loss, injury or suffering which may occur as a result of granting said permission and consent. The information above is true and accurate to the best of my knowledge. I have listed all OTC medications or other, if any, that I do not want my child to have while on The Webb School campus and/or in the care of any personnel of The Webb School. I have reviewed program activities and agree that my child may participate without restrictions unless listed above. ParenVGuardian Name (Print Please) ParenVGuardian Signature Date