THE MINI-TIME MACHINE MUSEUM SUMMER CAMP 2011 REGISTRATION A registration packet must be completed for each camper. After completion please return this packet by mail, fax or in person with payment. Once your packet has been received and your payment has been processed, you will receive a confirmation email from The Mini-Time Machine Museum of Miniatures. Full Day Camp (9am - 3pm) for children ages 8-11(after care from 3pm 5pm available for additional cost) Tuition: $155 members/$175 non-members After Care: $25 per week flat rate, per camper Session I, June 6-10 Dragons, Wizards and Fairies Session 2, June 20-24 Magical Flying Machine Session 3, July 11-15 A Petite Place Session 4, July 25-29 Mysterious Miniature Adventure Half Day Camp (9am - Noon) for children ages 5-7 Tuition: $80 members/$90 non-members Session 1, June 13-17 Fairy Tale Fun Session 2, June 27-July 1 Visit to a Secret Garden Session 3, July 18-22 Animal Adventure Camper s First Name: Camper s Last Name: Check session(s) attending Full Day Camp ($155 members/$175 non-members) After Camp Care ($25 per week flat rate, per camper) Session 1 After Camp Care Session 1 Session 2 After Camp Care Session 2 Session 3 After Camp Care Session 3 Session 4 After Camp Care Session 4 Half Day Camp ($80 members/$90 non-members) Session 1 Session 2 Session 3 We are members and qualify for the discounted rate. Membership ID # We would like to add a Family membership for $60 and receive the discounted rate for camp. Tuition Fee: $ After Camp Care: $ Membership: $ Total Due: $ I will be sending a check to The Mini-Time Machine Museum of Miniatures 4455 E. Camp Lowell Drive Tucson, AZ 85712 payable to The Mini-Time Machine Museum I will be paying with a credit card. Name on Card: Credit Card: Visa Mastercard American Express Discover Exp. Date Card Number Security Code Billing Zip Code The Mini- Time Machine Summer Camp 2011 Registration Page 1
WAIVER OF LIABILITY/PARTICIPANT INFORMATION SHEET This information sheet must be filled out completely before the participant will be allowed to attend any program. This form is used for all programs and is for the health and safety of the participant. If some questions do not apply, please indicate with N/A. PERSONAL INFORMATION Participant s name: Age: Sex: Male Female Guardian s Name: Guardian s Daytime Phone: Identify any behavior concerns, if any, and how to deal with them: Limitations or restrictions of activity or diet: This individual is free of infectious disease, is up to date on all immunizations, and is able to participate in recreation activities (with the limitations/restrictions listed). YES NO MEDICATION Is the participant taking medication? YES NO If yes, name of medication(s): Will medication be taken during program hours? YES NO If yes, please fill out separate Medication Form. Additional medical conditions we should be aware of (allergies, asthma, seizures, etc.): Any other information that would be helpful to staff: PARENT/GUARDIAN INFORMATION Parent/Guardian name: Relationship to participant: Address (if different): Mailing City ST Zip Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) E-MAIL: Parent/Guardian name: Relationship to participant: Address (if different): Mailing City ST Zip Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) E-MAIL: Are any other individuals permitted to pick up program participants? YES NO If yes, please list: Individuals will be required to show a picture ID when picking the participant up. The Mini- Time Machine Summer Camp 2011 Registration Page 2
EMERGENCY INFORMATION Person to notify in case of emergency (other than parent/guardian): Phone: Physician s name: Phone: _( ) Medical coverage: Group ID#: Preferred hospital: EMERGENCY CLAUSE in the event I cannot be reached in an emergency, I hereby give my permission to the employees of The Mini-Time Machine Museum to secure proper medical attention for my child as deemed necessary. This permission extends from minor first aid treatment to (under doctor s orders) hospitalization, injections, anesthesia, surgery, and other medical procedures deemed necessary. I DO I DO NOT MEDIA RELEASE: I hereby grant The Mini-Time Machine Museum permission to record the participant s likeness and/or voice for use in television, films, radio, or printed materials to further the aims of The Mini-Time Machine Museum in related campaigns and magazine articles, booklets, posters, and in other ways they may see fit. I DO I DO NOT RELEASE CLAUSE: The undersigned releases and holds harmless The Mini-Time Machine Museum and any officers, employees or agents thereof from any and all claims, liabilities, or demands whatsoever arising out of the enrollment or participation in any program by the participant therein. Signature of Responsible Party: Date: Relationship: The Mini- Time Machine Summer Camp 2011 Registration Page 3
MEDICATION POLICY/MEDICATION PERMIT The following information relates to your responsibilities if your child requires medication(s). For each medication required, a Medication Permit must be filled out and signed. Staff will not administer any medication that does not have a signed permit, including non-prescription medications. NO invasive medical procedures will be administered. All prescription medications must come in a pharmacy bottle with a legible pharmacy label on it. The label must contain the participant s name, the pharmacy s phone number, the name of the medication, dose and frequency required, and the doctor s name. All non-prescription medications must be submitted in the original sealed container with the participant s name, dose, and frequency clearly labeled on the container. MEDICATION PERMIT Participant s Name: Date of Birth: Age: Parent/Guardian name: Phone #: ( ) Name of Medication: Dosage: Instructions for giving medication: Possible side effects: Date From: Date To: I hereby authorize The Mini-Time Machine Summer Camp Staff to give the above named medication to as ordered by: Doctor For(condition): Parent or Guardian Signature Date Please return this form by mail, fax (520-881-9307) or in person at the museum. The Mini-Time Machine Museum of Miniatures 4455 E. Camp Lowell Drive Tucson, AZ 85712 The Mini- Time Machine Summer Camp 2011 Registration Page 4