Unitarian Universalist Congregation

Creative Capers Goes Green   2009 Registration Form (copy to a word processing program)

Camper’s Name_________________________________   boy____   girl____

Address_______________________________________________________

City______________________ State_______ Zip______________________

Parent(s)/Guardian Name__________________________________________

Home Phone_______________ Work Phone _______________ Cell _______________

Email ______________________________________________

Camper Grade in Fall____________  Date of Birth____ /____/_____

Camper T-Shirt size: (Please circle) Children's  M   L     Adult's  M   L  XL  XXL

Food and/or other allergies_________________________________________________

Other health concerns_____________________________________________________

Family Physician______________________________ Phone ______________________

Health Insurance Name____________________ Policy Number_____________________

Emergency Contact (Name and Phone)_________________________________________

Adult(s) authorized to pick up child from camp____________________________________

For all campers:  I hereby authorize Creative Capers to seek medical attention for my child in case of emergency.

     Parent Signature ________________________________  Date____________________

For all campers:  I hereby authorize Creative Capers to publish my child’s photograph and name in the Camp’s Newsletter or in other media settings that report camp activities to the public.

    Parent Signature________________________________    Date____________________

For campers in grades 3 and above, please give us your top 3 afternoon elective choices. Choose from: Art, Recorder, Newsletter, Yoga, Gadgets, Electronics, Cooking, and Gardening.  See brochure for details.

1.__________________  2.____________________ 3.____________________

PAGE 2

Tuition worksheet

Full Day Tuition 9 a.m. - 4  p.m.          ($225) ________ (For all entering 2-7 graders)

Half Day Tuition 9 - 12:00 p.m.          ($150)  ________ (For all entering 1st graders)

Early Arrival Care 7:45 - 9 a.m.           ($20)   ________

Late Pick-Up Care 4 - 5:30 p.m.          $20)   ________

Total                                                           $  ________

 Multi-sibling reduction ($25 off each child)  $_________

New Total                                                   $_________  

Note:  TUITION INCLUDES LUNCH FOR EVERYONE.

I wish to apply for a scholarship.  

Requesting Full Scholarship ___ Requesting Partial Scholarship ___ Amount  $__________

Indicate if your child qualifies for Free or Reduced Meals Program at School.   Yes__ No__ Please note:  Scholarship does not include early or late care.   All campers will need to pay for these services at registration.

For all campers:  I have enclosed my total of _______, payable to Creative Capers.  I understand there will be a $25 cancellation fee until June 30 and after June 30, there will be no refunds.

Parent Signature  __________________________        Date________________

Please mail this form and total check amount to Creative Capers, UUC, 520 Kanawha Blvd.  W., Charleston, WV 25302.  OR  you may pay in cash at the UUC office, Tuesdays through Fridays, 9 a.m. to 2 p.m.

Creative Capers has limited enrollment.  Applications will be accepted and approved on a first come/first served basis.  Please return your application as quickly as possible.  A waiting list will be established as needed.

Expect a confirmation letter in the mail in June.